[Kharon]

As it was in the beginning:-

Find the time; listen, learn and think.

You might want to consider the flight forecast for the ATR flight in question.

The wind in the area was forecast to be from the west to north-west and increase with altitude from 30 kt at 7,000 ft to 60 kt at 14,000 ft. South of Canberra, the winds above 10,000 ft were expected to be up to 20 kt stronger. Turbulence was forecast to be moderate in cumulus cloud and moderate otherwise at all levels throughout the forecast area

 
At 1506, while the crew was en route to Canberra, another area forecast was issued. There was little substantive change to the weather outlook; however, winds were forecast to ease by 5-10 kt and turbulence moderate now above 10,000 ft rather than at all levels.
 
The aerodrome forecast (TAF)20 for Sydney Airport, which was valid from 1100 until 1700,indicated that the winds were 10 kt from the south-east. There was no mention of turbulence in the area.The TAF for Canberra Airport that was in effect for the flight from Sydney to Canberra and the departure from Canberra, indicated that the forecast winds were from the west at 16 kt. There was no mention of turbulence.At the time that the aircraft departed Sydney, the Canberra Airport aerodrome meteorological report (METAR), which had a trend type forecast (TTF) current from 1430, indicated that the winds were 15 kts, gusting to 26 kt from the west-north-west with no significant weather. However, at 1500, 6 minutes after take-off, a revised METAR/TTF for Canberra Airport was issued noting that there was moderate turbulence forecast below 5,000 ft.
 
However, the bureau went on to advise that the balloon flight suggested a relatively strong inversion was developing during the day of the occurrence. The aircraft would have been traversing from a warmer stable atmosphere into a relatively cooler and unstable layer between 7,000 and 10,000 ft. This could account for any reported moderate turbulence.
 
Take a look at Fig.16 in the report. -  05:40:42 to 05:40:57 = 15 seconds with a 22 knots to 8 knots ‘drop’ in wind – 14 knots – for 15 seconds. Hardly 'dramatic'. Anyone ever skipped off the top of inversion - at Red line:?  How many FO's have been advised to back off the speed a bit?  - to be sure - to be sure.

[Peetwo]

Twenty five years; four tails; 478 funerals; a birdstrike; and a broken leg - Part III

Reference previous:

Find the time; listen, learn and think.

You might want to consider the flight forecast for the ATR flight in question.

The wind in the area was forecast to be from the west to north-west and increase with altitude from 30 kt at 7,000 ft to 60 kt at 14,000 ft. South of Canberra, the winds above 10,000 ft were expected to be up to 20 kt stronger. Turbulence was forecast to be moderate in cumulus cloud and moderate otherwise at all levels throughout the forecast area
 
At 1506, while the crew was en route to Canberra, another area forecast was issued. There was little substantive change to the weather outlook; however, winds were forecast to ease by 5-10 kt and turbulence moderate now above 10,000 ft rather than at all levels.
 
The aerodrome forecast (TAF)20 for Sydney Airport, which was valid from 1100 until 1700,indicated that the winds were 10 kt from the south-east. There was no mention of turbulence in the area.The TAF for Canberra Airport that was in effect for the flight from Sydney to Canberra and the departure from Canberra, indicated that the forecast winds were from the west at 16 kt. There was no mention of turbulence.At the time that the aircraft departed Sydney, the Canberra Airport aerodrome meteorological report (METAR), which had a trend type forecast (TTF) current from 1430, indicated that the winds were 15 kts, gusting to 26 kt from the west-north-west with no significant weather. However, at 1500, 6 minutes after take-off, a revised METAR/TTF for Canberra Airport was issued noting that there was moderate turbulence forecast below 5,000 ft.
 
However, the bureau went on to advise that the balloon flight suggested a relatively strong inversion was developing during the day of the occurrence. The aircraft would have been traversing from a warmer stable atmosphere into a relatively cooler and unstable layer between 7,000 and 10,000 ft. This could account for any reported moderate turbulence.
 
Take a look at Fig.16 in the report. -  05:40:42 to 05:40:57 = 15 seconds with a 22 knots to 8 knots ‘drop’ in wind – 14 knots – for 15 seconds. Hardly 'dramatic'. Anyone ever skipped off the top of inversion - at Red line:?  How many FO's have been advised to back off the speed a bit?  - to be sure - to be sure.

Excellent points you make "K", I would also question why the FDR and associated flight wx forecasts, sig wx reports etc. weren't analysed for the 13 sectors that followed and any recorded data leftover from the flights before the accident flight. This data would surely be invaluable in the analysis of whether the CRM breakdown and flying at VMO (redline fever) in or in the vicinity of forecast and recognised high risk mechanical turbulence areas, was a normalised operating deficiency; and I believe would have helped with the analysis that went into this part of the report:

 

Operator’s history of VMO exceedances


A search of the VARA occurrence database for overspeed events from 2012 to 2014 identified seven occasions where an ATR 72 crew reported a VMO overspeed event on descent. In these events, six of which were before the occurrence, the crew cited turbulence and/or distraction as contributing factors. Where target speed was reported, it was 230 or 235 kt and where details were provided about recovery actions, the reported crew actions were reduction of power, disconnection of autopilot, and manual nose-up input. The ATSB noted that there was no significant geographical pattern to the occurrences and that there were 14 reported flap overspeed events during the same period.

A search of the ATSB database also identified one report of a VMO exceedance in an ATR 72, while they were under the Skywest operation in June 2012. In that occurrence, the aircraft was on descent at about 240 kt, when the airspeed rapidly increased due to an atmospheric disturbance. At the time, the pilot monitoring was distracted by another operational task.

VARA also supplied a copy of all incident reports lodged by the flight crew involved in the VH‑FVR occurrence. Neither of those flight crew had lodged reports to the operator of an overspeed event, including flap, gear and maximum operating speed. - (P2#: refer pg 20-21 of the report for crew personnel details and experience  ) 

Extract from ATSB FR 'Safety Message' section:

...From an operational perspective, the event shows how a flight crew whose intention was to keep the aircraft within the prescribed limitations, can inadvertently expose the aircraft to a higher level of risk. When taking action to address potential aircraft exceedances, flight crew should consider the serious consequence of applying aggressive or large control inputs at high speed relative to the risk posed by the exceedance. Flight crew should also adhere to sterile cockpit procedures to optimise their performance in the higher risk phases of flight and apply the handover/takeover procedures to ensure dual control inputs are avoided or coordinated to maintain effective control.

In terms of continuing airworthiness, the conduct of an inspection may be the sole opportunity to detect aircraft damage. As such, to avoid a single point failure it is imperative that the form of the inspection be fit-for-purpose and for inspections to be effectively coordinated and certified.

For aircraft manufacturers and airworthiness authorities, there can be unforeseen consequences of aircraft design characteristics. It is important that when identified, these are recognised and addressed during operational service of the aircraft type..

   
  From the report under 'safety issues and actions' it states that:

Proactive safety action by Virgin Australia Regional Airlines and Virgin Australia Airlines 

Action number: AO-2014-032-NSA-051 Virgin Australia Airlines advised that, in response to this occurrence, they had taken action to reduce the potential for pitch disconnects and to manage the risk of adverse outcomes from such occurrences.

These included:

• reviewing and revising (where necessary) policy and procedures associated with descent speeds, handover and takeover procedures, overspeed recovery and on ground pitch disconnects
• incorporation of a number of factors surrounding the event into training material and simulator checks
• improved pilot awareness through Flight Crew Operations Notices, manufacturer’s communications (All Operators Messages) and on-going training and checking
• full induction for ex-VARA crew into the VAA safety management system
• updated maintenance requirements following a pitch disconnect
• compliance with all relevant points in the ATR All Operators Messages with respect to this event. 

 
The date on the proactive action is the 15 June 2016. In reality VARA (now VAA) had probably actioned through their SMS the identified operational safety issues within weeks of the occurrence happening.

However the proof is always in the pudding...  

https://www.flightglobal.com/news/articles/hard-landing-in-turbulence-damaged-virgin-australia-445098/

A hard landing in turbulence on 19 November 2017 resulted in substantial damage to a Virgin Australia ATR 72-600, say investigators in a preliminary report.

---

https://www.pprune.org/australia-new-zea...rra-2.html

&..

https://the-riotact.com/probe-launched-i...out/279335

The Australian Transport Safety Bureau said the incident involved an ATR-72-flight from Sydney on 13 December at 7 pm.

The aircraft was descending through heavy rain when the right engine flamed out, automatically re-starting within five seconds as it is designed to do. As the descent continued the left engine also flamed out, automatically relighting as before with the right engine.

But for the remainder of the flight and the landing, the crew opted for manual engine ignition.

The ATSB has deemed the incident as serious and has downloaded the flight data recorder and is gathering other information.

Now from a completely left field OBS - in relation to the CBR hard landing occurrence - I noted the following very disturbing update from ASN on the Moscow Superjet accident (my bold): AIOS - & the 21st Century??

Superjet in fatal Moscow crash had windshear warning on approach and bounced twice on landing
26 May 2019


The Russian Ministry of Transport released initial findings on the May 5 accident of a Sukhoi Superjet at Moscow’s Sheremetyevo Airport in Russia.

Aeroflot flight 1492 took off from Sheremetyevo Airport’s runway 24C at 18:03 hours local time on a scheduled service to Murmansk, Russia. Visibility was fine but there were some Cumulonimbus clouds near the airfield at 6000 feet.

The flight crew engaged the autopilot as the aircraft climbed through a height of 700 ft (215 m). At 18:08, as the aircraft was climbing through an altitude of about 8900 ft (2700 m), a failure occurred in the electrical system. At this point, the aircraft was 30 km west-northwest of the airport in an area of thunderstorm activity.

The captain assumed manual control of the aircraft and the crew managed to establish radio contact using UHF. The flight was not able to contact the approach controller and subsequently selected the emergency transponder code 7600 (loss of radio communication).

About 18:17 the aircraft overshot the runway centreline after turning to runway heading. Altitude at that time was about 2400 feet. The aircraft continued the right-hand turn, completed a circle and proceeded on the final approach for runway 24L. Flaps were selected at 25°, which was the recommended setting for landing above maximum landing weight.

At 18:26 the flight crew selected the emergency transponder code 7700 (emergency).

When descending from 335 to 275 m (1100-900 ft) the windshear warning system sounded five times: “Go around. Windshear ahead”.

From a height of 80 m (260 ft) above ground level, the aircraft descended below the glide path and at a height of 55 m (180 ft) the TAWS warning sounded: “Glide Slope.” From that moment on the airspeed increased to 170 knots.

At 18:30 the aircraft overflew the runway threshold and touched down at a distance of 900 m past the threshold at a speed of 158 knots. Touchdown occurred at a g-force of at least 2.55g with a subsequent bounce to a height of about 2 m. After two seconds the aircraft landed again on the nose landing gear with a vertical load 5.85g, and bounced to a height of 6 m. The third landing of the aircraft occurred at a speed of 140 knots with a vertical overload of at least 5g. This caused a rupture of the wing structure and fuel lines. Flames erupted and engulfed the rear of the aircraft. The aircraft slid to a stop on the grass between runway 24L and two taxiways. An emergency evacuation was then carried out while flames quickly engulfed the rear fuselage.

  
 Hmm...no comment but there will be definitely more to follow...   

In the meantime here is an extract from a 2015 Ventus AP post: 

My dear Gobbles:

The problem, simply put, is one of discombobulation.


In a crisis, the respones of modern systems, the changing displays, the cavalcade of warnings, and the lack of "familiar cues", completely discombobulate the crews.

The fact is, regardless of the howls of protest from the techno-nerds that design them, and those who love them "on paper" when in their arm chairs, in the "real world" the systems are actually discombobulating, ( ie, they throw the crew into a state of mental uncertainty ) and as a result, in a crisis situation, the crews quickly become completely discombobulated.

The result, is needless disaster, after needless disaster.

The "industry" will however, never admit to this truth.  

The industry has "acquired institutionalised ostrichitis syndrome" (AIOS).


So, stand by for regular repeats of AF-447 and QZ8501.


Clues:
confusion, befuddlement, bewilderment, puzzlement, perplexity, disconcertment, discomposure, daze, fog, muddle, etc ........

Five years, 3 months and five days to perfectly obfuscate and PC the bejeezus out of what could have been Australia's worst ever aviation disaster - UDB? Nope OPS normal in Oz Aviation's safety circus:



&..

 

TBC...P2 

Ps I stand corrected on the media coverage of this bollocks report, yesterday Airline Ratings published this by Steve Creedy:
https://www.airlineratings.com/news/auss...atr-upset/

[Kharon]

A hat trick – of warnings.

There are two ‘deep’ elements which ATSB have not deigned to cover off. Esoteric some would say; others would say it belonged to the new generation; some would consider company culture; there are some who would tag the observations as ego and attitude. To me, the elements above weave a pattern where airmanship, training and experience have been lost in the ‘hype’.

One can, and there is evidence supporting (BA for example) where the ‘problem’ begins with the HR folk. A cardboard cut out of the ideal crew – for company purposes – a ‘type’ if you like. You can, with almost 100% accuracy go to a pub and identify the company the individual’s fly for: won many a beer playing this game. There is little in the way of variation; which, for company purposes, is great. Not so much for having the right stuff somewhere on the flight deck. But, IMO it is a flawed philosophy – good pilots ain’t always ‘good’ corporate citizens – compliant and biddable; nor easily intimidated. A small, but important thread in the pattern.

P2 - The aircraft was descending through heavy rain when the right engine flamed out, automatically re-starting within five seconds as it is designed to do. As the descent continued the left engine also flamed out, automatically relighting as before with the right engine

To me this is tale is a warning flag; an indicator of pilot training and thinking error. “descending through heavy rain” – Why was the ‘spark’ not selected to manual (ON) before entering ‘heavy rain’. It should be an automatic action to turn the crackers on – long before entering; same as the icing gear – get it hot and working before – basic common sense. Training, corporate or pilot error? It costs maintenance money to replace the ‘crackers’ – but be buggered if I’d sit and wait five seconds for a relight even once – let alone twice. It took two flame outs before the crew selected ‘ON’. Tea and biscuits on my watch for that crew.  

P2 - A hard landing in turbulence on 19 November 2017 resulted in substantial damage to a Virgin Australia ATR 72-600, say investigators in a preliminary report.

We have all done it – thumped one on – hard. Quartering crosswind sneaking in behind; strong gusty conditions etc. But you really need to mess it up to damage an inherently tough airframe. You can – even OEI go around from a very low height – you can also ‘feel’ when the aircraft has become a well trimmed manhole cover and take preventative action; maybe you ‘bang’ it on – but you don’t break it.

P2 - A search of the VARA occurrence database for over speed events from 2012 to 2014 identified seven occasions where an ATR 72 crew reported a VMO over speed event on descent.

Speed excursions happen – not very often – certainly not with this monotonous regularity. Particularly during a descent phase. There is a great deal of difference between a professional assessment of the conditions and the descent profile being ‘worked’ to suit the ambient conditions, than simply programming the Auto to get you to 1500 feet at five mile from Kickinatinalong. Lots of time spent ‘discussing’ and ‘briefing’ the approach plate – but little on the conditions expected throughout the ‘descent’ phase. Over speed is a training and airmanship matter.

Seasoned, thinking pilots will understand the need to manage the whole process so as not to over speed the aircraft and wind up with a hard landing after two flame outs before selecting continuous ignition approaching in heavy rain. These three known items may not be potential killers – but by Golly, they are man made holes in that famous Swiss cheese. How this becomes a matter for ATR to solve is beyond my ken; this, before we even get to the meat and spuds of how the control channels became separated in fairly routine conditions between Canberra and Sydney; and, how ATR are expected to re-jig their aircraft to prevent terminal stupidity. More to follow – you can bet on it.

Aye well - back to my knitting. Before I do :-

Cute as a button. Or; funny coincidence department? – You pick. Either way it is a classic of ATSB aberrations; all part of being the PR extension for the big guns. I’m rattling on about the exquisite timing of the ATSB release of the long awaited report into the badly damaged ATR. Go figure the odds; five years and change we waited for the release and when does it happen?
 
Apart from Cready and Oz Aviation – the media completely missed this one; and, there is a story there, a scary one to boot. But what with the world watching the Moscow tragedy and the 737 Max brouhaha and some kind of conference; and, a federal election on the boil - ATSB choose this particular time to quietly slip this report into he public arena. Thing’s that make you go Hmm indeed.
 
Coincidence – not a ducking chance 
 
Toot – toot.

[P7_TOM]

Point of View.

As it happened; I was having a quiet Ale with a few ‘mates’ – nothing serious – just a catch up and a chinwag. One of the fellahin’s had a new fangled I-Pad and was  scanning AP; “read this?” says he: No, so  he read it out.

P9 – “Seasoned, thinking pilots will understand the need to manage the whole process so as not to over speed the aircraft and wind up with a hard landing after two flame outs before selecting continuous ignition approaching heavy rain.”

These were ‘senior’ experienced men listening; there was quiet for while; then almost simultaneously we all had the same scary thought. Bear with me, there is a point. Standardization – essentially the aircrew across a fleet should be doing pretty much the same thing. – You could, without drawing too long a bow, parlay that into a statement to the effect that they are all operationally at the same standard; one crew pretty much the same as the next (give or take). With a little imagination you could paint a shocking picture where the events mentioned could all not only happen to the ‘same’ crew, but to the majority of crew – standardization; or, normalized deviance, if you prefer. If one lot could do it - etc.

It leaves the impression that any ATR crew could be operating with the regular noted over speed (and the effect this has on air frame integrity) hitting some routine turbulence; disconnecting the control channel through non SOP; entering heavy rain on approach without continuous ignition, then making a heavy landing in an already seriously damaged aircraft. The next step is have the elevator channels reconnected, a quick inspection and the broken  aircraft returned to service for a further 13 sectors. You do realise that another ‘heavy landing’ or another rough ride in turbulence could have led to structural failure.

Us old folk quietly talked it through (as you do) the if’s the ands and the buts’ of it all. Then we applied the oldest test of ‘em all. “Would you let your wife and kids fly with this outfit? “ No prizes for guessing that answer. But the big question of course is – what the hell were ATSB playing at and where was a much self promoted CASA during the five year ‘investigation’. Seems to me some folk should be pulling their socks up, checking their belts and shortening their braces. No matter who drafted the ATSB report; or, more to the point whoever edited and approved the ATSB report should – IMO – be tarred, feathered and run out of Dodge on a rail. The report is even more dangerous than the entire stew of gross aeronautical errors. Scandalous.

Well, so much for old school thinking – a change of subject to happier matters; one for the road then home in time for dinner.

[Peetwo]

Fort Fumble White Hats; plus a thread drift? -   

Was reading the Flight Safety article on this latest abomination of a ATSB topcover report - see HERE - and basically it was like the others (Oz Aviation, Creedy) following the party line - nothing to see here, move along...   

Where the CASA White Hats totally lost me was when they included the following Hooded Canary propaganda quote:  

 ‘This serious incident demonstrates aircraft and aircraft systems need to be designed in anticipation of and tolerant to foreseeable inadvertent pilot actions. Aviation safety regulators and aircraft manufacturers need to address previously unforeseen aircraft design consequences during the operational life of an aircraft type.’

     
Where's the bucket Ol'Tom - 
In my mind this begs the question on why the White Hats even bothered? Then I read some of the comments which included these comments:

1. [img=50x0]https://secure.gravatar.com/avatar/5bac255c958966b36416b873b6726057?s=50&d=mm&r=g[/img]Walter May 29, 2019 at 2:06 pm
   Five years to produce this is a disgrace! We ought to be ashamed of ourselves for being so inept, but I guess this is Australia, a country not known to do anything efficiently or effective !
   Reply
   
   
   
2. [img=50x0]https://secure.gravatar.com/avatar/71c7b2cc25a3a87f64f9e0f203cbdb55?s=50&d=mm&r=g[/img]Phoenix May 29, 2019 at 2:10 pm
   Interesting that there is so much focus on the mechanical damage, and very little on the management failure that created the situation leading to damage. Surely the need for formal handover of control should have been emphasised? How many times will we keep seeing incidents arising from poor cockpit management and culture?
   Reply
   
   

 
And I thought maybe there is a method in their madness and so I included a comment on behalf of P9 - i.e his last post   
For the record, just in case it gets taken down:  https://www.flightsafetyaustralia.com/20...mment-2274

How things have changed? - NOT!
Now for a bit of a thread drift that I believe underlies the seriousness of this bollocks report.   
Over on the twitter-sphere yesterday I made the following reply to a tweet thread:  

2/2...read this 2014 @PlaneTalking (RIP Ben) article: https://blogs.crikey.com.au/planetalking...australia/ … &/or RT https://twitter.com/PAIN_NET1/status/456322171229306880 … then ask yourself what's changed. I would argue that it has only gotten worse: RT https://twitter.com/PAIN_NET1/status/113...1039585280 … & https://auntypru.com/forum/showthread.ph...1#pid10321 … + https://twitter.com/fishonoodle/status/1...5998066688 … #auspol

 
You can backtrack to understand the context if you like: ref - https://twitter.com/PAIN_NET1/status/113...6497699840

However my point in rehashing the 5 year old Ben Sandilands article (may he RIP -   ) is very much relevant timeline wise and in context with the point that Ben so clearly made way back then...  
 

"..The risks of ministerial administrative capture need to be shut down in Australia, before they become the focus of a Royal Commission into a preventable disaster.."

Right then thread drift over...err maybe? 


MTF...P2 

[Kharon]

P2 – “Where's the bucket Ol'Tom?”

That – is (I hope) a tongue in cheek understatement. We need a long drop outdoor dunny to deal with the copious amounts of Canary comment induced vomit from just the fatuous remarks department. I never though we’d miss Beaker, with all his faults even He would not say anything as risible as:-

Hood - “aircraft and aircraft systems need to be designed in anticipation of and tolerant to foreseeable inadvertent pilot actions.” (retch).

Seriously? – For Ducks sake. Backtrack the ATR event to weather briefing; fly along until the top of descent and watch as the aircraft is mindlessly configured for a ‘high speed’ descent; no mention of Turbulence penetration speed consideration; just punch the descent into the box and sit back – the turbulence was forecast and; as any pilot who ever flew between Canberra and Sydney will tell you – it can get ‘bumpy’. No ‘wind shear’ warning in any of the weather information – just turbulence and inversion (hint- hint).

"Recommended procedures: A simple rule of thumb would be to split the difference and fly a speed that is approximately half way between Vs1 and Va. However, a slightly faster speed will help improve controllability in very rough conditions. Since airspeed will be varying considerably in turbulence, it is not important that the pilot try to maintain an exact speed, but rather work to maintain near a level attitude and not exceed either the Va or Vs1 limits. The Continental Airlines B-737 Flight Manual offers the following excellent guidance which is also applicable to light aircraft, “The two major concerns when encountering turbulence are minimizing structural loads imposed on the aircraft and avoiding extreme, unrecoverable attitudes.”

So, Ok an experienced crew may not come all the way back to snail speed – but would/should build a ‘buffer’ between two extremes; keeping a few knots off the clock in case the speed picks up toward ‘risky’ and prevent not only ‘over speed’ but potential air-frame damage. Certainly fast enough to keep things ticking over nicely. Not rocket science – Airmanship, professionalism, understanding, due diligence and old fashioned common sense.

So Tweedledee and Tweedledum are bowling along – shock horror – the forecast inversion and the forecast moderate turbulence have caught them out. Too bloody fast mate – over speed approaching. OK – back off the power – ease the nose up - reduce the descent rate and proceed at a reduced speed. No brainer – routine – easiology. Nope, out hero’s elect to not only disregard SOP and manufacturer procedure; but engage in an arm wrestle for control. Can’t remember the number of foot/pounds needed to be deliberately applied to separate the elevator channels - but it is a big one, i.e. you have to mean it. So we have a situation where – at a relatively high speed – one side of the elevator gets an ‘UP’ command – the other a ‘DOWN’ force and, no surprise it breaks. Training error, discipline error, operational error, pilot error – maybe plain old panic and incompetence. Plenty of options there – one option though can easily be ruled out; manufacturer and design error. Hood speaks through his posterior orifice. Disgraceful, deceitful and wrong.

Not content with making a fool of himself in front of aircraft manufacturers and aircrew all over the world – he then tries to ‘piggy-back’ into the Boeing mess to try and give the impression that ‘he’ is a sage, experienced doyen of aircraft systems and their design.

Hood - “Aviation safety regulators and aircraft manufacturers need to address previously unforeseen aircraft design consequences during the operational life of an aircraft type.’

It is good thing he can speak through his posterior orifice – because he is full of it. Clown!

Toot – pass the bucket – toot.

Sotto voce – I ain’t done with this yet – not by a long march.

[Kharon]

Catch Up or Ketchup?

One of the worst things that can happen, in almost any field of endeavour is falling behind. The further behind one gets, the harder it is to catch up, much more energy and will power is required and, having expended that energy, getting ahead becomes a very real challenge. It takes a while and some thinking to fully grasp the implications for the Australian 'catchup' emanating from the excellent report into the Air Nuigini 'accident'. (?)

In less than a twelve month, the PNG AIC managed to produce not only a first class analysis, but recommendations which not only have merit, but will stick. Flying operations in PNG are not without risk; almost everyone concerned there has an elevated awareness of ‘real’ risk in ‘real’ time and have a vested interest in finding out what happened, why and how best to fix it to prevent a reoccurrence. There are no faery tales of ‘safety’ told in PNG, no spin to mislead the public into believing that the local CAA is a god like being which, through a myriad of complex rules can sit back and say you are safe. Not in PNG, they understand that terrain, weather, aircraft and pilot can combine in an accident – any tick of the clock – and they do what they may to prevent reality happening, with limited resources and going the extra mile, without fear or influence. They shame Australia.

Despite the spin, bullshit, resources, unlimited power; and, not to mention the minister on a string, Australia has an impressive list of unfinished fatal reports, an even longer list of unpublished recommendations, and a marked reluctance to complete any of the above within a reasonable time frame. If an emerging nation like PNG with limited everything can do a complex, world class report within ten months, why are we in Australia still waiting for results? It also begs the question why did we waste so much time and effort to hold not only a Senate inquiry, but an independent report and an international examination; which, combined produced almost 100 recommendations, to no effective change whatsoever?

P2 - It is also disturbing that despite there being a 2nd inquiry and report by the ATSB into the PelAir VH-NGA ditching that there was no observations/findings in regards to Pacific Island air services agreements etc. like the PNG AIC has been able to do, without fear nor favour, inside of 10 months to an excellent full report...

A good question for the opposition to ask the incumbent Muppet, masquerading as minister methinks.

Perhaps ask why there is such a delay on the final report into the Ross Air fatal for example; another ‘training’ based event which proved lethal. Many would like to hear the ‘official’ ministerial response to that event; or, of any of the serious events which are neatly stacked up in the waiting room, awaiting their final, properly edited turn to be of no practical value.  

How’s this for a response to an enquiry – two years (and counting) down the track of the Ross Air investigation (another sim v aircraft training accident).

ATSB - "The investigation is progressing well, however, the analysis phase is proving to be a complex process due in part to the lack of recorded data from the flight. As a result we now expect to provide you with a copy of the draft report in the 4th quarter of this year. Sincere apologies for the delay however this investigation remains a high priority for the ATSB and the team are working tirelessly to complete the investigation as soon as possible."

Here is one response:-

Anon – “but not too busy to try making ATSB keep up with their promise of monthly updates. What utter tosh! Here is a copy of the latest 'update'. As you can see he insults my intelligence by telling me the investigation is progressing well and they are working tirelessly!!! Can you believe the audacity???”

I, for one can, so can many others. Australian aviation ‘safety’ is rapidly becoming little more than a PR exercise for government ministers who just don’t want to address the rapidly growing elephant in the room. Perhaps someone could whisper into the ministerial ear the real opinion of his international peers regarding the pitiful, deceitful state Australian aviation governance has descended into.  Volunteers? No. I wonder why not.

Toot – toot.

[Peetwo]

Hooded Canary not singing but still talking bollocks - 



Via the Yaffa:

ATSB wears Kickback over Angel Flight Report
15 August 2019
    
The Australian Transport Safety Bureau (ATSB) has been roundly condemned by both Angel Flight and the Centre Alliance for its recommendations stemming from the Mount Gambier crash report released on Monday.

The report's recommendations into the VFR-into-IMC accident deliberately focused more on the systems and management behind Angel Flight than the actions of the pilot, suggesting that Angel Flight should consider using regular public transport rather than private pilots (PPL) because it was safer to do so.

Angel Flight CEO Marjorie Pagani slammed the report, saying that the ATSB focus was of no help to general aviation.

"The ATSB offered no safety recommendations to pilots flying light aircraft in bad weather," Pagani said in a statement. "It is regrettable that the Bureau made no relevant safety recommendations, nor gave any guidance whatsoever, to pilots flying in poor weather conditions – the cause of the accident.

"It would have been of benefit to the flying community had the ATSB focussed on these aspects of the accident.

"The safety recommendation made was for the charity to book people on airlines for travel. This does not adequately factor in cost (particularly where two or more people are traveling, which is often the case), nor does it properly factor in the infrequent scheduling or non-existence of airline flights into country regions across Australia, the inconvenience and difficulties faced by the elderly and families with young children at major city airports, and the associated ground travel; and appears to work on the assumption that city specialists and hospitals will gear their appointment times around airline timetables.

"Angel Flight does use airline flights where practicable and necessary, and will continue to utilise these services."

Centre Alliance's Senator Rex Patrick was openly critical in a statement released through Angel Flight. Senator Patrick has opposed the CASA-imposed restrictions on community service flights and was behind motions to disallow lodged in the previous parliament.

"The findings in respect of community service flights are intensely bureaucratic in nature and clearly written by people sitting at a desk in Canberra without reference to any of the thousands of families that have been helped by organisations such as Angel Flight," Senator Patrick said.

"Indeed, its hard to take the report’s analysis of Angel Flight seriously. It asserts that many flights can be replaced by commercial services almost blind to the costs of regional flights, their limited routes and their limited schedules. Indeed, the data the ATSB uses to support its claim are based on the very narrowest of data sets.

"The ATSB uses ‘lies, damned lies and statistics’, coupled with predominantly subjective analysis, to portray community service flights as unsafe. Angel Flights use experienced pilots and safe aircraft. There is no difference in the safety case associated with a CASA certified pilot flying a mate to the footy in Melbourne and a CASA certified pilot flying someone to chemo therapy in Melbourne, except the the ill patient is more aware of the qualifications of the pilots and the risks associated with a flight.

"Its Pel-Air (Norfolk Island ditching) all over again - for that particular report the ATSB were found to be grossly incompetent and were ultimately required to redo the report."

ATSB Chief Commissioner Greg Hood defended the investigation report, saying that investigators deliberately shied away from focusing on the pilot.

"If you have a look at the way the ATSB works, we've been broadly criticised, particularly over the Norfolk Island report where we focused on the individual, so with this investigation, given that it was the second triple-fatality, our methodology took us to having a look at organisational factors, and that's why we put in the recommendations we did," he told Australian Flying.

"We went to look at the organisational factors, and one of the problems we encountered is that we didn't have any data. There was no way to have a look at the safety of that particular sector of the industry because the data didn't exist.

"Being private flights they weren't required to state that they were Angel Flights, so what we had to do was ask AF for the schedules and then go back into the flight plan database and then the incident database and match that up to give us some idea of the health of the industry in relation to occurrences and accidents."

On the matter of the recommendation to place clients on RPT, Hood took pains to point out that the ATSB recommended only that Angel Flight consider using commerical flights in the same manner as the Canadian Hope Air, which places 70% of all clients with medical appointments on RPT.

Hood stated that the issue with using PPLs is that Angel Flight missions appeared to impart greater pressures to complete that flight than the ATSB believed are present during general private operations, leading to the conclusion that RPT would be a safer option.

"We did go to great lengths to be balanced," Hood said. "I know that's no everybody's view, but what we were faced with is two triple-fatalities and when we were able to extract the data it was telling us something very clearly in relation to these pressures and so then it was a matter of what recommendations do you make?

"The ATSB has no legislative powers to enforce any of these recommendations; they are there to improve the safety of the traveling public in these particular flights."

Angel Flight also took issue with the data analysis used in the reports, stating that the ATSB didn't use straight comparisons when assessing the levels of reported incidents and accidents.

"The ATSB also chose to compare only the passenger-carrying sectors of flights coordinated by the charity – it disregarded the flights, also coordinated by the charity, where the aircraft flew from home base to the city collection points, the return trips back to base, and the positioning flights to collect passengers from their own home towns," Pagani said

"It did, however, include those flights when reporting ‘occurrences’ against the charity flights. There was, and is, no reason for this failure. To remove up to two-thirds of the coordinated flights in order to make statistical conclusions is unjustifiable. Moreover, when comparing the data with private flights generally, it did not exclude the non-passenger flights for that group – all flights were counted in the general private sector, but not in the charity sector."

Angel Flight is currently contesting the data used by CASA to justify applying restrictions to Angel Flight operations last March, with the matter scheduled to be back before the courts again in September. According to Greg Hood, the ATSB did not rely on the CASA data, but used its own analysis to arrive at a similar conclusion, that Angel Flights were statistically more dangerous than normal private operations.

"We've done everything entirely separately from the regulator," Hood pointed out. "We've been very careful in that space especially after the experience we had with Norfolk [Island] and previous investigations, so we obtained the data from Angel Flight [and] we did our own analysis completely independent from anything that was done by the regulator.

"I'm absolutely confident in the science applied to this. We have a number of data scientists here with PhDs and we had one team developing the science and arriving at conclusions and another team making sure that that was valid.

"The ATSB just wants [Angel Flight] to operate well and for the people who are being carried to medical appointments to have that level of assurance that they're going to get there safely."

Read more at http://www.australianflying.com.au/lates...MDIj7qM.99

& via the Oz:

ATSB’s warning to pilots on risky flights: ‘Don’t push it, don’t go’



A new safety campaign urging ­pilots “don’t push it, don’t go” will be launched next week by the Australian Transport Safety Bureau following this week’s Angel Flight crash report.

That report found pilot Grant Gilbert should never have taken off from Mount Gambier on June 28, 2017, due to low-lying cloud and the fact he was only visually flight-rated. His TB-10 Tobago was airborne for just 70 seconds before the crash that killed him and his passengers, Tracy Redding and daughter Emily.

It was the second fatal Angel Flight crash in six years, with the previous triple-fatality accident in 2011 occurring in similar circumstances.

ATSB chief commissioner Greg Hood said the bureau’s finding that Angel Flight services were seven times more likely to result in a fatality than other private flights showed more needed to be done to improve safety.

“We have absolutely no barrow to push; we’re not anti-Angel Flight, we’re simply saying that the data is telling us something,” Mr Hood told The Australian.

“We’ve got two triple fatalities, you’ve got next of kin who are incredibly upset and we think that better things can be done in the sector.”

He admitted to being “taken aback” by the response from Angel Flight CEO Marjorie Pagani that the final report provided little in the way of useful guidance. She criticised the recommendation that Angel Flight consider booking commercial flights where available as an alternative to using volunteer private pilots, and said there was no advice given to pilots flying in poor weather.

Mr Hood said the best guidance the ATSB could provide was the message of their “don’t push it, don’t go” campaign.

“If the weather’s not suitable, you shouldn’t be flying,” he said.

“I don’t know how many times we’ve run these campaigns over the years, but pilots who are only rated to fly under visual conditions have continued to get themselves in trouble.”

The Australian understands as many as 100 incidents of pilots becoming spatially disoriented in cloud have been reported to the ATSB in the past decade, resulting in 21 fatalities.

Crossbench senator Rex Patrick said he would continue to push for new regulations imposed on Angel Flight by the Civil Aviation Safety Authority to be reversed, despite the finding that the community service operation had a higher fatality risk than other private flights.

“Angel Flight uses experienced pilots and safe aircraft,” Senator Patrick said. “There is no difference in the safety case associated with a CASA-certified pilot flying a mate to the footy in Melbourne and a CASA-certified pilot flying someone to chemotherapy in Melbourne except the ill patient is more aware of the qualifications of the pilot and the risks associated with a flight.”

But the ATSB argued that transporting patients to medical appointments carried greater responsibility and pressure, which had led to pilots taking off in unsuitable conditions.

Transport safety director Stuart Godley said it was important that pilots were trained how to recognise those pressures and deal with them, “rather than leave them alone to make those decisions in the heat of the moment”.

And in regard to O&O'ing reports...  

ATSB chief Greg Hood: More complex reports take time



Australian Transport Safety Bureau chief commissioner Greg Hood has defended the increasing time frame for aircraft incident investigations, pointing out the greater depth of recent final reports.

This week’s report on the 2017 Angel Flight crash at Mount Gambier went to great lengths to delve into organisational factors that may have contributed to the accident, and produce the statistics highlighting the risks involved with the not-for-profit operator.

Mr Hood said much of the data had to be sourced from scratch, after the ATSB discovered that what it needed for an examination of the safety of the community service flight sector did not exist.

“What we did is we went back and got more than a decade of schedules from Angel Flight and we matched those flights with data from the Bureau of Infrastructure, Transport and Regional Economics and also from the ATSB database,” he said. “(Statistician) David Wilson wrote the program that matched all that up and for the first time we were able to compare flights in the community service flight sector with private, charter and regular public transport.”

A number of investigations were close to being finalised including the 2017 Sydney Seaplanes crash and the Australia Day crash of a Grumman G-73 Mallard in Perth the same year.

 
Hmm...in the real world the Hooded Canary protestations would be all well and good, however the problem for Herr Hood is that he has a massive  credibility issue in all this because of his checkered past inside of both CASA and ASA. To say the guy is impartial and a SME (subject matter expert) would welcome hilarity from the more credentialed aviation accident investigation professionals throughout the world. 

Remember that this was the guy that as Chief Commissioner saw fit to threaten internally his employees with the possibility of jail time if they were contemplating leaking or having an opinion on the active (at the time) MH370 investigation and search - References:

Joining dots on Hood threat & obfuscation of MH370

..As witnessed above, currently there is much finger pointing, hand wringing, consternation and condemnation; on the ATSB's 'Hooded' threat to it's employees and attempted obfuscation of the Australian's FOI request for the recorded opinions of the various MH370 SSWG participants...

Well aided and nicely abetted.

..If the data Australia refuses to release belongs to Malaysia; then why does Hood simply just say so. “Sorry folks, if it were our data, we would release it without hesitation; but, it ain’t”. “If you want it, petition the Malaysian government, it all belongs to them”.  But Hood does not say this – clearly, that’s not case. So, like Higgins and Byron,  I’m left wondering just who is running this country? ..

And remember that this was the guy that was so severely intertwined within the PelAir cover-up (Mark I & II) to suggest a massive conflict of interest with any dealings with the ATSB, let alone being the Chief Commissioner...

References: 1. https://auntypru.com/forum/showthread.ph...38#pid8238 & 2. https://auntypru.com/forum/showthread.ph...29#pid8029

The Iron Ring & the Hooded canary -   

Quote from this week's SBG: Speak softly; yonder, as I think, he walks.

 "...The opening gambit is readily seen in the media – see: there’s Hood, doing a Geoffrey Thomas (he of Sunrise fame). This is not a top quality act, but ‘twill suffice. Firstly, we must examine the ‘props’ used, the title for a start will impress – ‘top dog in the Australian Transport Safety Bureau (ATSB) and a natural performer. Always seen looking ‘windswept’ and interesting, dressed in his canary yellow vest, wearing his ‘courage’ wrist band. The ‘shrinks’ would have a field day with that little lot, no matter. The long suffering public will not know the lack of qualification, or the association with some of the most disgusting ‘Acts of bastardy’ which hover about the ‘windswept’ visage. They will have no concept of conflicted interest or even ‘departmental’  manipulations. No; they just see the ‘fluff’ and hear the soothing words, reassured; they happily hop on the cheapest flight and toddle off to booze in Bali..."

 &.. from SBG post #95:

"...The main reason being that while HVH was the CASA Executive Officer ultimately overseeing the enforcement actions against both PelAir and Dominic James I also have, on good authority, information that HVH was the designated co-ordinator/liaison officer dealing with the FAA audit team and therefore the consequential cover-up of the actual FAA findings that could have led to the possible Cat II IASA rating..." 

So with interest piqued the BRB have tasked me to re-examine the HVH crumb trail with the intent to join some further chronological dots & dashes on the PelAir cover-up timeline (i.e Pel-Air: A coverup: a litany of lies?)... 

  
MTF...P2 

[Choppagirl]

Well. What a surprise. The Rossair investigation report has been delayed until 2020 even though the team are 'working tirelessly'. Makes you wonder what on earth they can be doing!

[Kharon]

Wonder no more….

CG – “Makes you wonder what on earth they can be doing!”

If you get a chance to read the Larry Vance* book on MH 370 (Kindle $8.00), take a little time to study his remarks regarding the ATSB. 
*Larry Vance, who was a senior investigator for the Canadian Transport Safety Boar


There are several passages in the book which draw pretty much the same conclusions as many professional accident investigators and senior aviators have. Vance is quite ‘diplomatic’ but very clear about it, ATSB write reports to a pre determined result. An acceptable conclusion is then supported by carefully managed data.

We have seen this phenomenon several times over the last years; we have also seen ‘time’ used to allow a less palatable result of investigation to drift from active memory. Ross Air a perfect example; the Braz another, Essendon another, the ATR another; all part of an extensive list.



There are two ‘classic’ examples – Pel-Air and Angel Flight, where the inherent willingness to oblige with a ‘slanted’ report is clearly apparent. IMO -  the MH 370 story, in professional hands provides the best example of an investigation report being written to fit a pre-determined outcome.

Anyway – FWIW in terms of changing the ATSB the book is probably irrelevant. The sad thing, as the evidence against ATSB piles up is that their reports become worthless, rendered  nugatory, because no one believes 75% of the rubbish presented. The 25% believable is simply the stark fact that there was, in fact, an accident. But we already knew that, didn’t we boys and girls.

Stopping there: before Hell's own ‘Furies’ arrive.

Toot - toot.

[Peetwo]

The Hooded Canary takes the ATSB well "Beyond All Sensible Reason" - 



Long post but there is a point (I hope - ) - the chain of disconnection/evidence: 

A hat trick – of warnings.

There are two ‘deep’ elements which ATSB have not deigned to cover off. Esoteric some would say; others would say it belonged to the new generation; some would consider company culture; there are some who would tag the observations as ego and attitude. To me, the elements above weave a pattern where airmanship, training and experience have been lost in the ‘hype’.

One can, and there is evidence supporting (BA for example) where the ‘problem’ begins with the HR folk. A cardboard cut out of the ideal crew – for company purposes – a ‘type’ if you like. You can, with almost 100% accuracy go to a pub and identify the company the individual’s fly for: won many a beer playing this game. There is little in the way of variation; which, for company purposes, is great. Not so much for having the right stuff somewhere on the flight deck. But, IMO it is a flawed philosophy – good pilots ain’t always ‘good’ corporate citizens – compliant and biddable; nor easily intimidated. A small, but important thread in the pattern.

P2 - The aircraft was descending through heavy rain when the right engine flamed out, automatically re-starting within five seconds as it is designed to do. As the descent continued the left engine also flamed out, automatically relighting as before with the right engine

To me this is tale is a warning flag; an indicator of pilot training and thinking error. “descending through heavy rain” – Why was the ‘spark’ not selected to manual (ON) before entering ‘heavy rain’. It should be an automatic action to turn the crackers on – long before entering; same as the icing gear – get it hot and working before – basic common sense. Training, corporate or pilot error? It costs maintenance money to replace the ‘crackers’ – but be buggered if I’d sit and wait five seconds for a relight even once – let alone twice. It took two flame outs before the crew selected ‘ON’. Tea and biscuits on my watch for that crew.  

P2 - A hard landing in turbulence on 19 November 2017 resulted in substantial damage to a Virgin Australia ATR 72-600, say investigators in a preliminary report.

We have all done it – thumped one on – hard. Quartering crosswind sneaking in behind; strong gusty conditions etc. But you really need to mess it up to damage an inherently tough airframe. You can – even OEI go around from a very low height – you can also ‘feel’ when the aircraft has become a well trimmed manhole cover and take preventative action; maybe you ‘bang’ it on – but you don’t break it.

P2 - A search of the VARA occurrence database for over speed events from 2012 to 2014 identified seven occasions where an ATR 72 crew reported a VMO over speed event on descent.

Speed excursions happen – not very often – certainly not with this monotonous regularity. Particularly during a descent phase. There is a great deal of difference between a professional assessment of the conditions and the descent profile being ‘worked’ to suit the ambient conditions, than simply programming the Auto to get you to 1500 feet at five mile from Kickinatinalong. Lots of time spent ‘discussing’ and ‘briefing’ the approach plate – but little on the conditions expected throughout the ‘descent’ phase. Over speed is a training and airmanship matter.

Seasoned, thinking pilots will understand the need to manage the whole process so as not to over speed the aircraft and wind up with a hard landing after two flame outs before selecting continuous ignition approaching in heavy rain. These three known items may not be potential killers – but by Golly, they are man made holes in that famous Swiss cheese. How this becomes a matter for ATR to solve is beyond my ken; this, before we even get to the meat and spuds of how the control channels became separated in fairly routine conditions between Canberra and Sydney; and, how ATR are expected to re-jig their aircraft to prevent terminal stupidity. More to follow – you can bet on it.

Aye well - back to my knitting. Before I do :-

Cute as a button. Or; funny coincidence department? – You pick. Either way it is a classic of ATSB aberrations; all part of being the PR extension for the big guns. I’m rattling on about the exquisite timing of the ATSB release of the long awaited report into the badly damaged ATR. Go figure the odds; five years and change we waited for the release and when does it happen?
 
Apart from Cready and Oz Aviation – the media completely missed this one; and, there is a story there, a scary one to boot. But what with the world watching the Moscow tragedy and the 737 Max brouhaha and some kind of conference; and, a federal election on the boil - ATSB choose this particular time to quietly slip this report into he public arena. Thing’s that make you go Hmm indeed.
 
Coincidence – not a ducking chance 
 
Toot – toot.

Plus:

Cracks in the ‘deeper’ foundations?

Over the last 12 month; I have, looking through the boarding passes done 20 domestic sectors – four international and four domestic ‘overseas’ - as a passenger. I get about a bit – back and forward to work.

The four overseas sectors were in the USA – lovely smooth landings – as usual from well managed approaches, despite the traffic and schedule – no complaints, operationally whatsoever. The ‘usual’ 'whinges' are purely personal preferences.

Of my domestic sectors – only four were on Virgin; two into Brisbane, two into Sydney. They were the last I ever flew with that airline – totally and utterly the very last. The first ’scare’  was into Brisbane – being sensitive to the handling of the aircraft, my own little alarm started ring about 20 miles out. By 18 miles, the aircraft felt and sounded like there was a ‘speed/ glide-path control problem; by about 14 miles, I was convinced that there was little control over either – hard landing approaching I reckoned. Proved correct – IMO the resulting landing, from that approach was indeed ‘heavy’. I was much surprised to see the aircraft taxi out again about 30 minutes later. When an almost picture perfect repeat of this event happened this occurred, a couple of weeks later; I simply decided not to ever again fly on a line where aircraft were not under complete control during the approach, made earth shattering landings and taxied out ‘on schedule’ after what was, by any reckoning a very hard landing and significant bounce..

I did two sectors with Tiger – no complaint whatsoever, the approach was nicely managed, the landing most acceptable.

The rest I did with Qantas. Same sectors over a three month period – out and back. Not once, was I subjected to a landing I would deem ‘acceptable’. Bang, crash, wallop – big reverse and some fairly sloppy taxi-ing, along with harsh braking.

Now, they ‘discover’ cracks in air- frames – Wow!   I wonder how they happened?

HR have a lot to answer for; profiling to find ‘the right type’ of corporate citizen to fit their mould of ‘what’ makes for a decent pilot. Used to be an ability to actually manage the aircraft – alas; no longer it seems. Not to worry – its all about the ability to type 60 WPM with your left hand and reliance on the ability to manage the software.

Aye, us Dinosaurs must learn to look the other way – toward the blessed day when ‘travel’ is no longer a requirement. Soon, very soon – I won’t have to give a monkeys; or fly anything that is repeatedly ‘slammed onto a runway’ - driven, no matter what – onto the markers at the scheduled speed, rather than ‘flown on’. “Oh, I do ‘em like that all the time” – the old answer to a ‘greaser’ in a fluky crosswind – off a hand flown ILS, middle of the night. Of course it was a fluke  - but I have ‘fluked’ it quite a lot of times. Enough to know the difference anyway. Not my problem - as are the repair and rectification bills.

Just saying my two bob’s worth – cracks in airframes ain’t a good thing; are they? However, now is the time for all good men of legal age to imbibe. BRB full session to ‘manage’ – the boy wants his new keyboard back – time for a quiet, calm, reflective Ale, before the BRB/IOS storm.

Yesterday the ATSB finally released their report into the ATR heavy landing at Canberra airport - 

  Via the Oz:

Virgin plane damaged after pilots’ stuff-up



The pilots of a Virgin Australia aircraft that landed so hard it was substantially damaged, were undergoing flight checks at the time, an Australian Transport Safety Bureau investigation has revealed.

The ATSB’s final report on the incident at Canberra Airport on November 19, 2017, found the pilots failed to adhere to standard operating procedures as the ATR 72 descended.

To make matters worse, a check captain was on the flight deck conducting an annual line check of the captain and a six-month check of the first officer.

According to the report, just four seconds from landing, the aircraft was descending at a rate of 784 feet per minute – or more than 200 feet per minute above the normal descent rate.

“At that time, the aircraft was subjected to a significant change in the wind from a 10 knot headwind component to a 2 knot tailwind component,” the report said.

“This resulted in a further loss of lift and the captain later stated he felt the aircraft drop out from under him.”

READ MORE: Qantas tests London to Sydney | Rex gets go ahead for foreign pilots

As a result, the turboprop reached a recorded 928-feet per minute descent rate at touchdown, resulting in a 2.97G hard landing on the main landing gear, tail skid and underside of the rear fuselage. All were substantially damaged.

The ATSB investigation found the power was incorrectly set for descent, but despite calling twice for an increase, the captain who was the pilot monitoring, did not physically intervene until it was too late.

The call for a go-around was made just as the aircraft touched down. Fortunately none of the 67 passengers or five crew on board were hurt.

ATSB transport safety executive director Nat Nagy said the crew should have conducted a go-around when the approach became unstable.

“This occurrence demonstrates the importance of crews adhering to standard operating procedures,” Mr Nagy said.

“It also highlights the risks associated with incorrect handling of an approach to land, and the need for prompt and decisive action, as the available time to remedy an unstable approach situation is short.”

He noted that unstable approaches continued to be a leading contributor to approach and landing accidents, and runway excursions or overruns.

The report revealed the captain had more than 8000-hours of flying experience and the first officer, 1320-hours.

In response to the incident, Virgin Australia had amended ATR 72 operational documentation, and reinforced existing training regarding speed management during approach and landing.

 
And the accompanying Hooded Canary MR: 

Unstable approach, failure to go-around leads to a hard landing


[b]The ATSB is highlighting the importance of adhering to standard operating procedures following the release of a final investigation report into the hard landing of an ATR 72 airliner resulting from an unstable approach.[/b]

On 10 November 2017, ATR 72-212A VH-FVZ operating as Virgin Australia flight VA646 was arriving at Canberra Airport in conditions of light turbulence. On the flight deck were the captain (who was also a training captain), the first officer (who the captain had previously trained), and a check captain. The check captain was conducting a routine annual operational line check of the captain and a six-month operational line check of the first officer over four flights on the day. The occurrence flight was the last of these flights. In the main cabin were two cabin crew members and 67 passengers.

During the landing approach the first officer, who was the pilot flying, assessed that the aircraft was overshooting the desired approach profile. In response, at a height of 118 feet above the runway, he reduced engine power to idle, but this resulted in an abnormally high descent rate (in turboprop aircraft large propellers spinning rapidly in low pitch create a significant increase in drag).

The aircraft captain, who was the pilot monitoring, identified that power was incorrectly set, and twice called for an increase in power before subsequently intervening and increasing power himself. This intervention, however, occurred too late to arrest the high rate of descent.

Four seconds prior to touching down, the aircraft was descending at a rate of 784 feet/minute, already greater than the design limit of the undercarriage and above the normal descent rate for the approach of about 575 feet per minute. At that time, the aircraft was subjected to a significant change in the wind from a 10 knot headwind component to a 2 knot tailwind component. This resulted in a further loss of lift, and the captain later stated that he felt the aircraft drop out from under him.

Consequently the aircraft reached a recorded 928 feet per minute descent rate at touchdown, resulting in a 2.97 G hard landing on the main landing gear, tail skid and underside of the rear fuselage, resulting in substantial damage.

Unstable approaches continue to be a leading contributor to approach and landing accidents and runway excursions.

The aircraft subsequently required inspection of landing gear components, reskinning of sections of the fuselage underside, and replacement of the tail skid and a drain deflector mast before it could return to service.

“The continuation of the approach when a go-around should have been conducted allowed the subsequent conditions to develop, leading to the hard landing,” ATSB Executive Director Transport Safety Nat Nagy said.

“This occurrence demonstrates the importance of crews adhering to standard operating procedures and conducting a go-around when an approach becomes unstable.

“It also highlights the risks associated with incorrect handling of an approach to land, and the need for prompt and decisive action, as the available time to remedy an unstable approach situation is short.”

Mr Nagy noted that unstable approaches continue to be a leading contributor to approach and landing accidents and runway excursions. No shit Sherlock -  

[b]Read the report AO-2017-111: Hard landing involving ATR 72, VH-FVZ, Canberra Airport, Australian Capital Territory on 19 November 2017[/b]

Which brings me to this O&O'd / yet to be completed, investigation within a completed investigation...  

Ref: https://www.atsb.gov.au/publications/inv...-2017-100/

...As part of the occurrence investigation into the in-flight pitch disconnect and maintenance irregularity involving an ATR72, VH-FVR (AO-2014-032) investigators explored the operator's safety management system (SMS), and also explored the role of the regulator in oversighting the operator's systems. The ATSB collected a significant amount of evidence and conducted an in-depth analysis of these organisational influences. It was determined that the topic appeared to overshadow key safety messages regarding the occurrence itself and therefore a separate Safety Issues investigation was commenced to outline the implementation of an organisation's SMS during a time of rapid expansion, along with ongoing interactions with the regulator.


The investigation will examine the chronology of the operator's SMS implementation and some of the key issues encountered. This will include:

• interviews with current and former staff members of the operator, regulator and other associated bodies
  
  
• examining reports, documents, manuals and correspondence relating to the operator and the methods of oversight used
  
  
• reviewing other investigations and references where similar themes have been explored.
  

 
Note that the last update states the expected completion of this investigation as the '1st Quarter 2020' but the investigation status is only listed as 'evidence collection', so early 2020 is optimistic at best ...   Shirley, given the above evidence the Hooded Canary could put a little bit more priority towards completing that investigation...  

This brings me to the other former high profile completed investigation that has an associated investigation within an investigation: https://www.atsb.gov.au/publications/investigation_reports/2017/aair/ao-2017-024/   

Ref: https://www.atsb.gov.au/publications/inv...-2017-100/

..On 21 February 2017, a building that is part of the Essendon Airport Bulla Road Precinct retail centre was struck by a Beechcraft King Air B200 (VH-ZCR). The ATSB’s preliminary report for this accident was published in March 2017. This preliminary report stated that the approval process for this building would be a matter for further investigation.


The building was part of the Bulla Road Precinct Retail Outlet Centre development, which was proposed by the lessee of Essendon Airport in 2003 and approved by the Federal Government in 2004.

Due to the specialist nature of the approval process and airspace issues attached to the retail centre development, and not to delay the final report into the accident from February 2017, the ATSB has decided to investigate this matter separately.

The investigation will examine the building approval process from an aviation safety perspective, including any airspace issues associated with the development, to determine the transport safety impact of the development on aviation operations at Essendon Airport.

A final report will be released at the conclusion of the investigation. Should a critical safety issue be identified during the course of the investigation, relevant parties will be immediately notified so that appropriate safety action can be taken.

  
To which I add this post link which highlights the snail pace progress of yet another investigation that you would think would have a much higher priority : Strange dissonance in the Hooded Canary's coop? - Part II

...The Essendon crash deserved the ATSB’s very best efforts; it could have been a serious disaster, with magnified ramifications. Yet it was quickly concluded that it was all pilot error, nothing to see and the ATSB would concentrate on whether the building measured up to ‘Black letter’ approval. For starters, ATSB are not in the ‘airspace game’ nor are they forensic legal experts on ‘approval’ to build, particularly in light of the convoluted processes used. So why was the aircraft and pilot quickly dismissed in favour of some half-baked ‘investigation into what Hood claims was a ‘life-saving’ building. It’s bollocks – ATSB’s job is to tell us, as best they can, from the charred remains – why this aircraft crashed and claimed five lives; difficult as that maybe... 

&..from this Airports thread post: A duty of care. - Part II

3)

Patrick Hatch article: ..The Australian Transport Safety Bureau found that pilot error was to blame, but while looking into the crash, decided to launch a separate investigation into how the DFO complex was approved "from an aviation safety perspective".

That probe is nearing completion, with its final report currently out for review by the parties involved ahead of its public release...

Hmm...why do I get the impression that not only are the powers to be actively avoiding addressing the significant holes in the Swiss cheese that these high profile accident investigations have identified but are also actively engaging in contributing to making the holes bigger to help facilitate the next high profile accident?   



 

MTF...P2 

[Kharon]

Its the Bullshit which baffles, bothers and bewilders..

Mr Nagy noted that unstable approaches continue to be a leading contributor to approach and landing accidents and runway excursions.

That is about the only honest line in the latest load of Pony-pooh from the ATSB PR division. Even so, it fails (miserably) to mention one important fact. This type of event is a ‘flight school’ common occurrence; instructor pilots earn their corn teaching proper approach and landing technique. Ask any experienced instructor how many times they have patiently nursed a neophyte through the ‘proper’ management of an approach and how ‘alert they are to this type of basic error occurring. By the time a pilot gets to fly an ATR, preventing this type of event should be a reflex action; long before imitating a well trimmed manhole cover. Ye Gods; managing the aircraft through turbulence, wind shear, crosswinds, wind gusts etc. are a routine part of daily life; yet here we see three (3) pilots with front row seats, who on fine day, without any problems, sat through a crash. WTD………

At that time, the aircraft was subjected to a significant change in the wind from a 10 knot headwind component to a 2 knot tailwind component. This resulted in a further loss of lift, and the captain later stated that he felt the aircraft drop out from under him.

I’m having a hard time even believing the statement above, let alone that the conditions cited had any bearing, whatsoever, on an aircraft supposedly crewed by ‘professional’ pilots. FDS there are these things called wind socks; there is a thing which tells you speed (in the air and over the ground)_, there is a thing which tells you how fast you are descending, there is even a thing to tell you, at about three miles this is getting out of shape – do something – that is good training and experience. Perhaps one of these elements was missing?

“The continuation of the approach when a go-around should have been conducted allowed the subsequent conditions to develop, leading to the hard landing,” ATSB Executive Director Transport Safety Nat Nagy said.

I say BOLLOCKS. Had the original causes been identified, the approach should have been under control long before ‘crash – down’. This was a good day to be flying, good enough for a hand flown visual approach, with every conceivable external factor benign, a serviceable aircraft and a tiny wind shift for the last 30 feet. My Grand Mama could land it with all that going for her. Go around – bullshit; thumb in bum, mind in neutral applicable. This was a typical pre solo student pilot error, overseen and watched by two supposed ‘training pilots’ all the way to the wreckers yard. Bloody disgraceful.

“It also highlights the risks associated with incorrect handling of an approach to land, and the need for prompt and decisive action, as the available time to remedy an unstable approach situation is short.”

The time to remedy an unstable approach is not when ‘time is short’. The time to remedy an unstable approach is at flight school, not on a passenger service with 60 odd in the back, on a good day.

No excuses the Australian Tenuous Substandard Bullshit (ATSB) can pen will remove the major problems. Double flame outs (One crew) – Tail plane damage (One crew) – Crash landing (one crew) that’s seven (7) pilots complicit in three (3) nearly serious events. Yet ATSB only spouts ‘go around’ early. Sage advice? – BOLLOCKS.

Aye, steam off; but there is something seriously wrong. You can kill yourself and your passengers as often as you like –provided it’s all done nice and ‘legal’ like. Don’t worry if you can only fly the Sim – and a wizard on the software – that’s what modern pilots do best, dontchyaknow. “Bong - Autopilot disengaged” “OMG we all be killed”. “Did you sign off the paper work” – Famous last words – thank the gods we’re legal. -  Cue CRASH sounds and screams.…
Toot – toot.

[Peetwo]

Hmm..I smell a RRAT??

Supplementary Estimates - WQON.

(N.B AQON for Sup Estimates are due 06/12/19)

ATSB:

Question on notice no. 387

Senator Glenn Sterle: asked the Australian Transport Safety Bureau on 8 November
2019—

What is the status of the following investigations?
o AO-2016-084
o AO-2017-066
If these investigations are still classified as "pending", when do you expect them to be
finalised?
Is there a time period within which ATSB would normally expect investigations to be
complete?
In the case of AO-2017-066 why was the aircraft diverted to Perth rather than landing
at its nearest alternative, Learmonth? Is this considered best practice?
In relation to investigation AO-2015-084:
o What recommendations were included in this report?
o Have all recommendations been adopted by the airline?
o Does ATSB hold any concerns about the safety of this airline to operate in
Australia?

P2 - These are the ATSB investigations in the order that Sen Sterle mentions them:
 

AO-2016-084

AO-2017-066

AO-2015-084

In the curious book of passing strange coincidences I note that after 1200 days the AO-2016-084 investigation was officially discontinued on the 7 November 2019 - 

Discontinuation notice published 7 November 2019


Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the Australian Transport Safety Bureau (ATSB) to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.

On 26 July 2016, the ATSB commenced an investigation into a loss of separation between a Jetstar Airbus A320 registered VH-VFO and an Air Asia X Airbus A330 registered 9M-XXC, near Gold Coast Airport, Queensland.

The Airbus A330 was departing Gold Coast Airport for Auckland, New Zealand while the A320 was arriving from Avalon, Victoria. Both aircraft were in visual meteorological conditions and the flight crews of both aircraft had the other aircraft in sight.

At the request of air traffic control, the flight crew of the A330 reported the A320 in sight and was instructed to pass behind that aircraft and climb. As the A330 climbed, both flight crew received a Traffic alert and collision avoidance system (TCAS)[1] Resolution advisory (RA).[2]Separation reduced to about 600 ft vertically and 0.35 NM (650 m) laterally. The required separation standard was 1,000 ft and 3 NM (5.6 km).

An Airservices Australia (Airservices) internal investigation into the occurrence identified the following safety issue:

Visual-pilot separation is not applied internationally in Classes A, B and C airspace. This may result in pilots of foreign registered aircraft not being familiar with their requirements and obligations when subject to this form of separation.

In response to the identified issue, safety action was undertaken to:

Review the risks of the application of visual pilot separation as applied to foreign registered aircraft. In determining its ongoing feasibility, with these operators, ensure any identified risks are appropriately managed

That review was conducted and resulted in a recommendation to:

Remove PASS BEHIND as a stand-alone phraseology for assigning pilot visual separation. (Note: could still be used in conjunction with other phraseology e.g. MAINTAIN SEPARATION WITH (AND PASS BEHIND).

The review also recommended that the following rule changes be considered in regard to assigning visual separation:

• Changing phraseology from MAINTAIN SEPARATION WITH to MAINTAIN OWN SEPARATION WITH. (alignment with ICAO phraseology)
• Restricting the use of pilot visual separation for jet traffic to sight and follow scenarios. That is, no ‘pass behind’ for jets.
• Limiting the application of pilot visual separation for foreign registered aircraft to sight and follow situations.

Airservices subsequently advised that it intends to implement the review recommendation and also the phraseology rule change described in the first dot point of the review considerations.

The ATSB reviewed the Airservices reports, safety issues and safety actions. Based on this review, the ATSB considered it was unlikely that further investigation would identify any systemic safety issues. Consequently, the ATSB has discontinued this investigation.

  

WTD?  - Funny how the discontinuation notice was issued around the date that the ATSB would have received the QON from Sen Sterle and the RRAT Committee? 


Hmm...I smell a RRAT?? - MTF...P2 

[Peetwo]

Slow news day for Ironsider??

 Via the Oz:

---

Virgin ‘near collision’ with pilot academy aircraft being investigated





The Virgin Australia ATR 72 involved in a near collision with a pilot academy aircraft at Albury airport.

ROBYN IRONSIDE
AVIATION WRITER
@ironsider

1:53PM DECEMBER 3, 2019
8 COMMENTS

An investigation has been launched into a “near collision” between a Virgin Australia passenger flight and a light aircraft from the Australian Airline Pilot Academy near Albury Airport.

On October 19, a Virgin Australia ATR 72 was coming straight in to land on runway 25, when the pilot academy’s Piper PA-28, which was performing a circuit, turned in front of the larger aircraft at about 1300 feet.

A traffic collision avoidance system alert sounded in the Virgin Australia plane and a missed approach was conducted to increase separation and avoid a crash.


A statement from Regional Express (Rex) airline which runs AAPA said they were “aware of the investigation and would fully co-operate with the ATSB”.

A Virgin Australia spokeswoman said the safety of passengers, crew and aircraft was always their number one priority.

“Virgin Australia will co-operate with the ATSB throughout the course of its investigation,” the spokeswoman said.

“The Virgin Australia Group is supportive of an industry approach, alongside other operators and regulators, to address greater awareness of all safety issues to ensure the safety of all aircraft, crew and passengers when in the airspace.”

As part of the investigation, the ATSB would interview directly involved parties and obtain other relevant information, including recorded data.

The final report was expected to be released by mid-2020.

The ATSB was also examining a ground strike by a Singapore Airlines Cargo Boeing 747 freighter at Sydney Airport last Thursday night.

About 10.40pm the freighter’s No.1 engine pod struck the ground during a missed approach.

Flight radar data showed the aircraft briefly touching down, before climbing to an altitude of 2900 feet.

As part of the investigation, the ATSB planned to interview the flight crew and other directly involved parties and obtain other information such as data from the cockpit voice and flight recorders.

That investigation was also expected to be finalised by mid-year.

The Australian Transport Safety Bureau (ATSB) is investigating a separation issue involving a Virgin Australia ATR 72, VH-FVR, and an Australian Airline Pilot Academy Piper Aircraft PA-28, VH-XDI, near Albury Airport, on 19 October 2019.

Passing 1,300 ft on a straight in approach to runway 25 at Albury Airport in visual meteorological conditions, the flight crew of the ATR 72 received a traffic collision avoidance system alert on the PA-28, which was turning final for runway 25. The flight crew of the ATR 72 conducted a missed approach to increase separation between the two aircraft. 

As part of the investigation, the ATSB will interview directly involved parties and obtain other relevant information, including recorded data.

A report will be released at the end of the investigation. Should a critical safety issue be identified during the course of the investigation, the ATSB will immediately notify relevant stakeholders so appropriate and timely safety action can be taken.

---

Not exactly sure why it has taken Ironsider so long to pick up on this occurrence? Perhaps RI has been trolling the ATSB database for Virgin/REX related occurrences? 


MTF...P2 

[Kharon]

Beyond belief. And yet:-

“Passing 1,300 ft on a straight in approach to runway 25 at Albury Airport in visual meteorological conditions, the flight crew of the ATR 72 received a traffic collision avoidance system alert on the PA-28, which was turning final for runway 25. The flight crew of the ATR 72 conducted a missed approach to increase separation between the two aircraft.”

I would like to see a transcript of all radio communications; just for a start. “Suddenly, out of nowhere a Cherokee materialised in front of our aircraft” Bullshit.

Once again the spectre of piss poor airmanship from yet another Virgin ATR crew emerges. Think about it – TCAS would flag the traffic; local VHF frequency would be used to sort of a sequence; was this crew another ‘asleep at the wheel’ episode? Every day at hundreds of non controlled aerodromes; turbo prop transport aircraft and ‘other’ aircraft manage to sort out their timing and self separate. We’ve all done it – widen the circuit, extend downwind, overfly and follow – any one of the dozen options – with or without TCAS employed on a daily basis to avoid the ‘suddenly our windscreen was filled with an aircraft’ excuse.

I can wait the mandatory three years for the ATSB to polish up the PR press release. Seems passing strange that only the Virgin ATR fleet, out of the entire turbine fleet providing public transport seem to have these on going ‘operating’ problems; it is quite a list now. There is little excuse for this one.

Toot – toot.

[Peetwo]

TICK TOCK goes the mystique of aviation safety playschool clock - 

A couple more for the mix...

Via the Oz:

---

Storms, parachuting blamed for mid-air near-miss



Thunderstorms, a parachuting competition and a breakdown in communication between air traffic controllers have been blamed for putting a Qantas and a Virgin Australia aircraft on a collision course west of Brisbane last year.

The final report on the incident by the Australian Transport Safety Bureau, said the Qantas flight to Brisbane and Virgin Australia flight to Proserpine were on reciprocal tracks in the Amberley airspace when a loss of separation occurred between the two Boeing 737-800s.

The situation was partly attributed to the fact the Qantas aircraft was being controlled by the Royal Australian Air Force (military) ATC, and the Virgin plane was on a Brisbane (civil) frequency.

The report noted the two operated non-linked air traffic management systems which “did not share a common display”.

“The departing Virgin Australia aircraft from Brisbane entered Amberley airspace without a hand-off from Brisbane ATC and without instructions to the crew to change to the Amberley frequency,” the report said.

“This resulted in the aircraft monitoring an incorrect frequency on entry to Amberley airspace and Amberley ATC initially unable to communicate with the flight crew.”

A change of controller in Brisbane added another 17-seconds to the four-and-a-half minutes it took to resolve the “impending conflict” with the Amberley ATC initially contacting the wrong operator.



When communication was established, the aircraft was diverted away from the Qantas plane which is when the breakdown in horizontal and vertical separation occurred.

Instead of the minimum separation distance of 3 nautical miles horizontally and 1000 feet vertically, the 737s passed each other at 2.1 NM and 650 ft.

The report said the presence of “a rapidly moving weather front likely increased the workload for the Brisbane departures controller” in addition to the World Parachuting Championships which had upped aircraft co-ordination requirements.

ATSB director of transport safety Dr Stuart Godley said the investigation highlighted the importance of “clear communication and co-ordination between air traffic controllers, operating in different, yet immediately adjacent airspace”.

“It also highlights the need for a clear understanding of the responsibility for separation assurance especially when operating without a shared traffic picture,” Dr Godley said.

A number of measures had been introduced by Airservices Australia and the RAAF in response to the incident, including dedicated communication lines between Amberley ATC and Brisbane departures south.

The report also noted that “the relevant parties were working together to implement a solution to ensure separation assurance between Brisbane departing aircraft and Amberley traffic during weather diversions”.

Dr Godley added that the successful recovery of separation illustrated the effectiveness of the conflict resolution training received by air traffic controllers in loss of separation events.

Ref: https://www.atsb.gov.au/publications/inv...-2018-070/

---

Hmm...anyone care to mention the OnePie white elephant in the room?? - Nah didn't think so...  


Ref: https://auntypru.com/not-only-captive-cu...loving-it/

Oh well my bets for the 25th running of the embuggerance cup are firming up...

Hint: 

#SBG 3/11/19: An Ode, to an Odious Commode.

 

St Commode strikes a low blow on CASA critics??



Ref: https://auntypru.com/forum/showthread.ph...5#pid10855

Plus via the UP:

Glenb - Legal update

---

Good morning folks.

I will get back on during the day or evening, and I must be somewhat careful.

Firms have been met with.
Some people of "note" who have been able to facilitate introductions to firms and personnel that I could not have achieved alone.
A substantive team has been decided.
Two meetings have been conducted.
An ENORMOUS body of well documented files by person and topic have been prepared submitted and reviewed two weeks ago to the legal firm
An initial review has been completed.
At this stage it is worth proceeding.
The firm contacted me yesterday, and generated the first invoice of $9990 was been given to me yesterday.
I attempted to transfer funds for that payment, last night but was limited by a $1000 limit.
The invoice will be paid in full today for Stage One.

For CASAs clarity. At this stage, I am reviewing my options. No legal action has formally commenced, therefore CASA should continue as normal at this stage. This is simply the process funded to see whether or not I have a valid basis for a claim.

Until that action is commenced, CASA are fully aware that my preference is a resolution through well intentioned face to face dialogue. Multiple formal requests have been made, and they have not been accepted by CASA.

If CASA force me to initiate a large law case, it will happen if CASA choose this as their most preferred option.

On receipt of the first transfer,which will be made today, the process will commence.

Regarding the Go Fund Me. This is for legal expenses only. It is not a case of "use some of the money for lawyers".

My living expenses are my responsibility, and as a family we will attend to those matters.

The generous donations made by supporters will be used for legal matters only.

Should I get this to the Courtroom as is my desire, it will clearly be seen, how may times I tried to avoid this path. It will be clearly evident that CASA forced me down this path.

Tragically, if CASA cannot apply the standards of governance and ethics that are expected of them, the irony is not lost on me that i have to actually initiate a large legal action to ensure that CASA does apply those standards that are imposed on them.

I might be the first person to take a safety regulator to court to make sure they actually do their job.

This entire process could have been avoided, had CASA followed their own Regulatory Philosophy and Administrative law.

There can be no doubt that CASA have already invested many hundreds of thousands of dollars into bringing me down.

Funds and peoples time that should have been directed to aviation safety has been redirected to crushing me.

Irrespective of the legal determination, a very public display of the culture of CASA is now clearly on record.

---

Para377 (Gobbledocks twin Kiwi Bro across the ditch -  ):

Is the timing right, finally??

---

Scomo, the Pentecostal speaker of tongues, recently announced his boning of some of the APS head piggies, rolling 18 departments into 14, sadly it would appear that once again CASA escapes the Grim Reapers sickle, an opportunity well missed. What is interesting is that Mike MrDak spent around 20 years as the head Secretary of Infrastructure, which had CASA in its portfolio. Smart bureaucrat, a survivor, but one that had no control over CASA in reality. He went across to Communications as Secretary and has fallen on his sword over the Robodebt disaster, amongst other things. So with the biggest changes to the APS since the 1980’s, maybe Glen’s timing is the gift we’ve all been hoping for?

Glen’s case at this point in time might be fortunate in some respect. This Government is certainly not very embracing of bad publicity or high level incompetence, so perhaps Glen’s actions are enough of a blowtorch application to force the CASA rocks in Canberra to be moved. The organisation needs a complete overhaul in its executive level, a change of direction, a change of department name, and the removal of the last Iron Ring members and their fledglings waiting in the wings.

All good viewing from the armchair....

---

GlenB:


A good question. Why do i continue to engage with CASA

---

I comprehend that there are individuals on these posts that have "industry leading knowledge" of the legal aspects of my case. The weighting of those contributions is acknowledged, appreciated, noted, and accepted. This thread is a very public record, and would be essential reading for anyone involved in my matter with similar levels of expertise. A valuable network has also been established. I also appreciate that such learned persons would look at thiks from a more prcatical and emotional standpoint than i.

The legal argument is only one aspect, and that will be played out i assume in a Court of Law. Recall that this matter commenced 6 months before i went public on PPRuNe, when i became convinced that i had no other option. What you have seen on here, is the mere tip of the iceberg, i can assure you. All will be revealed.

I have never blindsided CASA. I have forewarned them of my next course of action, confidentially on all occasions. They have made decisions, and effectively chosen the path of this journey. Multiple, well intentioned and fair options have been presented. The Board has had every opportunity to determine if ,in their opinion, the principles of good governance have been applied.

But this entire situation by its very nature has a bigger purpose. I will transfer those funds to the lawyer 15 minutes before the bank closes today, but that will officially be the end of any opportunity for well intentioned engagement. I will be seen to do everything i reasonably can to avoid that path, right up until the last minute. That opportunity finishers at Bankers hours today.

It will be disappointing. I have been in courts before and had some pretty big "issues" with Companies such as BDO (multinational), Toyota, Fairwork, and never had to use a lawyer.

The process is simple. You turn up. You turn up well intentioned. You tell the truth. A learned person makes a decision. You shouldn't need a lawyer.

You need a lawyer when you have concerns the other party will turn up, but may not be well intentioned, or may not tell the truth. I recognise I definitely need a lawyer!!!!!!

This argument must be played out in public because it is much bigger than Glen Buckley and affected parties getting fairly compensated.

CASA has chosen to make it a bigger argument, not me.

The truth is ( I hope this doesn't come out the wrong way, gulp)

If I was a Chinese Australian, an Indian Australian, a Philippine Australian, or any other newer Australian. If I was a female. I would have failed, and I still may. Unfortunately for CASA I was born here and from day one every Australian value has flowed through my blood. A small team of bullying men, isn't going to stop me.

Unlike any other Country in the world. I know that if I firmly dig my heals in for what is right, and stand by my ethics, act only in the truth, am well prepared, and steadfastly refuse to be bullied or intimidated by CASA, I will actually prevail, and I know it.

Its just unfortunate for CASA that they picked on me. There is no safety case. There was no accident, no plane slid off a runway or even dinged a wingtip. No rules were breached and still CASA remain unable to make a decision.

If this matter does not effect the required change in CASA the industry really is doomed, and sadly I will agree with Dick Smith on this matter.

It will effect change.

It may be that the law firm comes back and says. Glen. Your right. Those men ( and they are only men) aren't very pleasant, and they certainly pushed the boundaries but they gotcha.

In that case it will be over for me, but a very public record will be left. Eventually change must come. Lets just hope that it comes quick enough that all the well intentioned personnel within CASA can stick it out, and operate in the environment that they would prefer to operate in.

Assuming that i have to go to the bank late today, i suggest that Mr Graeme Crawford the Aviation Group Executive Manager who would be the accountable person i assume, would walk across to Dr Alecks office (Executive Manager of Legal and Regulatory Affairs) and say "Here, have your baby back".

Irrespective PPRuNe provides my one and only forum. I chose it, because it is appropriately discrete, as opposed to other social media options, i can get support via these pages and until you've walked in my shoes you wont appreciate how important that has been, and continues to be.

The legal argument is one argument, my challenge is to continue on here and not compromise that process. If anybody believes that any comment on here may compromise that process, i would appreciate them reaching out, and establishing contact.

Cheers. Glen.

Everyones involvement on these pages is important and appreciated.

Next...

Via the Oz:

---

 Regional runway confusing trainee pilots



A pilot training school has suggested special flashing lights may be needed at a regional NSW airport after the ninth case of “runway misidentification” in five years.

The two most recent incidents occurred on October 14 when student pilots doing solo flights lined up to land on the taxiway at Coffs Harbour instead of the runway as directed.

An Australian Transport Safety Bureau report noted the students had been made aware of the potential to misidentify the runway during a navigation exercise briefing immediately before the flights. “They were thoroughly briefed and provided with methods to confirm the correct runway, particularly when approaching from the north,” the report said.

Despite the detailed briefing, as the aircraft came closer to the airfield air traffic control was forced to intervene as the students aligned their final ­approach with the taxiway.

The ATSB report said a further seven similar incidents had taken place at Coffs Harbour airport in the past five years but no specific safety recommendations were made. All but one incident involved student pilots doing solo flights and on each occasion air traffic control stepped in to avoid a potential disaster.

Head of operations at Professional Pilot Training, Robert Loretan, said it was surprising such incidents could occur at the airfield, given there was a warning in Airservices Australia’s ­departure and approach procedures (DAP) chart.

“Anyone using proper procedures should not get into that situation,” said Mr Loretan, whose students were not among those involved in the misidentification incidents. “The only thing that could be done (to stop it) is approach lighting, or a flashing light to make it clear which is the runway and which is the taxiway, but that would be very ­expensive.”

The airport’s location “right on the coast” meant it was often used by people unfamiliar with Coffs Harbour, Mr Loretan said.

Coffs Harbour Aero Club spokesman Alan Kneale was surprised that “anyone could mistake the taxiway for the runway” because of the vegetation around it. “We’ve seen airlines line up on the taxiway and there is a warning on the documents that it can be mistaken,” he said. “When you get low visibility the problem gets worse.”

The ATSB said it would continue to monitor instances of runway misidentification at Coffs Harbour but the rate of ­occurrences and their “low consequence” had not triggered a transport safety investigation.

In an unrelated incident, the ATSB was investigating a near collision at Albury Airport involving a pilot academy aircraft and a Virgin Australia flight.

On October 19, the Virgin Australia ATR 72 was coming into land at Albury when a Piper PA-28 owned by the Australina Airline Pilot Academy turned into its path at about 1300 feet.

The traffic collision avoidance system activated in the Virgin plane, and the pilot conducted a missed approach to avoid a crash.

ATSB ref: https://www.atsb.gov.au/publications/occ...-2018-063/

---

As the DA 40 joined the final approach, the pilot advised ATC that they were on a 3 NM final, however the aircraft was unable to be sighted. ATC subsequently observed the DA 40 on final approach to taxiway E5. The controller advised the pilot that the aircraft appeared to be on final for taxiway E5, and that runway 21 location was to their left. The pilot turned left and reported runway 21 in sight. The aircraft landed without further incident.

Hmm...whatever happened to checking runway alignment with compass or DG heading? Oh well at least they weren't lining up on a coal loader - 



Ref: https://www.newcastleherald.com.au/story...or-runway/ & https://blogs.crikey.com.au/planetalking...-stuff-up/

TICK..TOCK indeed Mick Mack -

MTF...P2 

[Peetwo]

Can'tberra: Last one to leave - please turn the lights out?

Hmm..I smell a RRAT??

Supplementary Estimates - WQON.

(N.B AQON for Sup Estimates are due 06/12/19)

ATSB:

Question on notice no. 387

Senator Glenn Sterle: asked the Australian Transport Safety Bureau on 8 November
2019—

What is the status of the following investigations?
o AO-2016-084
o AO-2017-066
If these investigations are still classified as "pending", when do you expect them to be
finalised?
Is there a time period within which ATSB would normally expect investigations to be
complete?
In the case of AO-2017-066 why was the aircraft diverted to Perth rather than landing
at its nearest alternative, Learmonth? Is this considered best practice?
In relation to investigation AO-2015-084:
o What recommendations were included in this report?
o Have all recommendations been adopted by the airline?
o Does ATSB hold any concerns about the safety of this airline to operate in
Australia?

P2 - These are the ATSB investigations in the order that Sen Sterle mentions them:
 

AO-2016-084

AO-2017-066

AO-2015-084

In the curious book of passing strange coincidences I note that after 1200 days the AO-2016-084 investigation was officially discontinued on the 7 November 2019 - 

Discontinuation notice published 7 November 2019


Section 21 (2) of the Transport Safety Investigation Act 2003 (TSI Act) empowers the Australian Transport Safety Bureau (ATSB) to discontinue an investigation into a transport safety matter at any time. Section 21 (3) of the TSI Act requires the ATSB to publish a statement setting out the reasons for discontinuing an investigation.

On 26 July 2016, the ATSB commenced an investigation into a loss of separation between a Jetstar Airbus A320 registered VH-VFO and an Air Asia X Airbus A330 registered 9M-XXC, near Gold Coast Airport, Queensland.

The Airbus A330 was departing Gold Coast Airport for Auckland, New Zealand while the A320 was arriving from Avalon, Victoria. Both aircraft were in visual meteorological conditions and the flight crews of both aircraft had the other aircraft in sight.

At the request of air traffic control, the flight crew of the A330 reported the A320 in sight and was instructed to pass behind that aircraft and climb. As the A330 climbed, both flight crew received a Traffic alert and collision avoidance system (TCAS)[1] Resolution advisory (RA).[2]Separation reduced to about 600 ft vertically and 0.35 NM (650 m) laterally. The required separation standard was 1,000 ft and 3 NM (5.6 km).

An Airservices Australia (Airservices) internal investigation into the occurrence identified the following safety issue:

Visual-pilot separation is not applied internationally in Classes A, B and C airspace. This may result in pilots of foreign registered aircraft not being familiar with their requirements and obligations when subject to this form of separation.

In response to the identified issue, safety action was undertaken to:

Review the risks of the application of visual pilot separation as applied to foreign registered aircraft. In determining its ongoing feasibility, with these operators, ensure any identified risks are appropriately managed

That review was conducted and resulted in a recommendation to:

Remove PASS BEHIND as a stand-alone phraseology for assigning pilot visual separation. (Note: could still be used in conjunction with other phraseology e.g. MAINTAIN SEPARATION WITH (AND PASS BEHIND).

The review also recommended that the following rule changes be considered in regard to assigning visual separation:

• Changing phraseology from MAINTAIN SEPARATION WITH to MAINTAIN OWN SEPARATION WITH. (alignment with ICAO phraseology)
• Restricting the use of pilot visual separation for jet traffic to sight and follow scenarios. That is, no ‘pass behind’ for jets.
• Limiting the application of pilot visual separation for foreign registered aircraft to sight and follow situations.

Airservices subsequently advised that it intends to implement the review recommendation and also the phraseology rule change described in the first dot point of the review considerations.

The ATSB reviewed the Airservices reports, safety issues and safety actions. Based on this review, the ATSB considered it was unlikely that further investigation would identify any systemic safety issues. Consequently, the ATSB has discontinued this investigation.

  

WTD?  - Funny how the discontinuation notice was issued around the date that the ATSB would have received the QON from Sen Sterle and the RRAT Committee? 


Hmm...I smell a RRAT?? - MTF...P2 

Hmm...yet another one for the AirAsia X dirt file? - UDB! 

Report slams AirAsia X incident decisions and failure to follow procedure

Thai AirAsia X's A330-300 which will be operating Bangkok Brisbane flights from June.

ROBYN IRONSIDE
AVIATION WRITER
@ironsider

6:44PM DECEMBER 19, 2019

The crew of an AirAsia X flight from Sydney to Kuala Lumpur opted to divert to the furtherest airport available when one of the A330’s two engines failed.

An Australian Transport Safety Bureau investigation into the incident on August 16, 2016, revealed a series of misjudgements by pilots who initially failed to recognise the problem.

The final report found that as the Airbus A330 flew over Alice Springs, a shaft failure of the right engine oil pressure pump triggered a level 3 alert requiring immediate crew action.

But instead of following procedures and reducing thrust before shutting the engine down, the pilots increased thrust in the belief the alert was a false indication.

After about four minutes, the engine was returned to normal operations but it soon stalled and then failed completely, resulting in the pilots shutting it down.

At this time the pilots made the decision to divert the aircraft, which was only operating with one of its two engines. But instead of heading to Alice Springs which was 30-minutes away, or Adelaide, 75-minutes away, they chose to go to Melbourne – a flight time of 115 minutes.

“This increased the time that the aircraft was operating in an elevated risk environment,” the ATSB report observed.

On the way to Melbourne, the pilots tried twice to restart the right engine, contrary to the operator’s procedures.

“Despite available evidence and cumulative evidence to the contrary, the flight crew determined that the right engine was not damaged and could be restarted,” said the report.

“Both restart attempts failed.”

ATSB transport safety director Stuart Godley said there were three key safety messages from the investigation.

“Not only does this occurrence demonstrate the importance of flight crews adhering to standard operating procedures when responding to aircraft system alerts, it also highlights that those procedures need to be designed with clarity,” Dr Godley said.

“Further, the investigation report identifies that where there is not a need for an immediate response, that flight crews look at the full contextual and available information before deciding on a plan of action.”

According to the ATSB report, the captain on the flight in question had 8700-hours of flying experience including 2540 on A330-type aircraft. In the 90-days prior to the incident, the captain had logged 244-hours. The first officer had 3265-hours of flying experience.

Since the incident, the Southeast Asia-based low cost carrier has restated the operational requirements for flight crews for engine restarts and diversion decision-making.

AirAsia X has also used the occurrence as the basis for a training package for responding to engine failures, restarting failed engines and diversion decision-making.

And for official version from Dr ATCB (God help us -   ) Godley...

Engine failure incident highlights importance of following procedures


[b]The flight crew of an AirAsia X Airbus A330 did not follow proper procedures when faced with an engine oil pressure warning, attempting to restart the affected engine even after it had failed, as well as electing to divert to Melbourne when the aircraft was considerably closer to two other airports.[/b]

The engine oil pressure warning and subsequent engine failure occurred during a 16 August 2016 scheduled flight from Sydney to Kuala Lumpur, with two flight crew, eight cabin crew and 234 passengers on board. While in cruise near Alice Springs the flight crew received an ‘Engine 2 oil low pressure’ failure alert message, which the ATSB’s subsequent investigation of the event established was due to a shaft failure in the engine’s oil pressure pump.

That alert required immediate crew action comprising of reducing thurst on the affected Rolls-Royce Trent 700 engine to idle and then, in accordance with the Airbus procedure, ‘if [the] warning persists’, shutting down the engine.

Procedures need to be designed with clarity

However, the flight crew probably misinterpreted the term ‘persists’ as requiring they wait a certain period of time to determine if the condition was persisting. As a result, they continued to troubleshoot the failure, rather than shut down the engine.

After monitoring the engine the flight crew formed the view that the warning was the result of a gauge failure. With the intent of further trouble shooting, the crew then increased the engine’s thrust. This led to the engine stalling and ultimately failing.

However, despite evidence to the contrary, the flight crew determined that the failed engine was not damaged and could be restarted.

Consequently, and contrary to the operator’s procedures, the flight crew made two attempts to restart the failed engine, even though there was no safety risk to the aircraft that demanded a restart attempt. Both attempts failed.

Also contrary to the operator’s procedures, the flight crew elected to divert to Melbourne following the engine failure, rather than to closer suitable airports in Alice Springs and Adelaide. Although twin-engined airliners such as the A330 are designed to fly safely on a single engine, this decision increased the time that the aircraft was operating in an elevated risk environment of single-engine operations.

“There are three key safety messages from this investigation,” noted ATSB Director Transport Safety Dr Stuart Godley.

“Not only does this occurrence demonstrate the importance of flight crews adhering to standard operating procedures when responding to aircraft system alerts, it also highlights that those procedures need to be designed with clarity,” Dr Godley said.
“Further, the investigation report identifies that where there is not a need for an immediate response, that flight crews look at the full contextural and available information before deciding on a plan of action.”

Since the incident, AirAsia X restated the operational requirements for flight crews for engine restarts and diversion decision making. Further, the airline has also used the occurrence as the basis for a training package for responding to engine failures, restarting failed engines, and diversion decision making.

[b]Read the report AO-2016-101: Engine failure involving Airbus A330, 9M-XXD, 445 km SE of Alice Springs, South Australia, on 16 August 2016[/b]

Meanwhile, in a parallel hemisphere a long way from the fantasy world of the aviation safety Wizards of Oz, the USA's NTSB quietly gets on with the business of proper ICAO Annex 13 aviation accident investigation...

NTSB_Newsroom
@NTSB_Newsroom
·
8h
NTSB Opens Public Docket, Thursday, Dec. 19, 2019, for investigation of Atlas Air Flight 3591 Cargo Plane Crash; https://go.usa.gov/xp72V

---

Via Avherald:

Crash: Atlas B763 at Houston on Feb 23rd 2019, loss of control on approach

By Simon Hradecky, created Thursday, Dec 19th 2019 16:34Z, last updated Thursday, Dec 19th 2019 18:22Z
On Dec 19th 2019 the NTSB opened their public docket, no preliminary report was released so far.

Editorial notes: Information is spread over a flurry of different group reports and data files. It is thus very difficult to work out what might have contributed to the crash. There is one shout in the CVR transcript, that stands out and does not fit the scenario the aircraft performance study paints. The FO exclaims: "12:38:45.9 CAM-2 (where's) my speed my speed [Spoken in elevated voice.]" What does this mean? Did he lose the speed indication? Did his speed indication go outside the flight envelope prompting the following "stall" calls? Did the first officer refer to his feel rather than the instruments when he called the stall? And why would the captain also provide nose down inputs if his instruments were good just with the first officer shouting, or were the fligt controls still connected with the first officer pushing both yokes forward? But then, why would the captain still provide nose down inputs on the left hand elevator, though to a less extent than the first officer, after the elevators split? How did the Go Around Mode activate? What role played the apparent ADI/HSI failure and the EFIS Switch mentioned by the First Officer, was the switch indeed moved and the indications returned to normal, or was the switch not moved and the first officer saw erroneous data on his ADI/HSI? In summary, the docket does not yet provide any clear indication of all the facts leading to the crash...

Meanwhile downunda Mick Mack has declared Wagga the capital of Australia...

Ref: https://www.canberratimes.com.au/story/6...l-capital/



MTF...P2 

[Kharon]

Airframe ignorant – Operationally savvy.

My vast working knowledge of Airbus could be transcribed onto the back of a matchbox – with room left over for the Magna Carta. However, the Air Asia X ‘incident’ and the ATSB’s eventual report– HERE – from an operational POV is worth a thought or two.

The report itself is framed in a very ‘authoritarian’ manner no if’s considered and no but’s at all. Taken as read, the report goes to some length to reinforce the ‘by the book’ gospel of black letter compliance. Supporting the CASA doctrine of removing big picture thought and command prerogative from the equation. No doubt there were errors made – a warning which calls for an engine shut down is only ignored at your own peril – that’s a given no brainer. Not too much in the way of tea and biscuits at the management meeting. No sympathy whatsoever regarding the attempted re-lights. No idea what a replacement engine is worth, but compared to the cost of an oil pump shaft – righteous fury well warranted.

Some of the points raised by ATSB are valid in relation to the engine management procedures; there is a need for clarity and detailed information – which; time permitting – as it was in this case – could have prevented the mishandling and subsequent damage bill. But that aside was the flight actually ever ‘at risk’?

There is a post on the UP – HERE – by SWH which, IMO, supports the diversion to Melbourne. What is not mentioned within the ATSB report is ‘company advice’ and communications. ATSB also fail to discuss ‘operational logic’. Adelaide, Alice or Melbourne were on the cards for non threatening (not emergency) situation – Melbourne would be the most convenient for the company. Was there any company influence involved in the command decision process?

SWH – “My biggest criticism of the report is the apparent lack of understanding of the aircraft weight, fuel system (no fuel dump), and drift down profile of the A330. It will take around 90 minutes for a single engine drift down from FL380 at green dot. At the end of the drift down they would be TOD for MEL”.

SWH – “An immediate diversion to ASP would result in an unplanned overweight landing onto a shorter runway at night at higher density altitude with reduced flap setting at an airport they never operate into.

SWH – “Amber LAND ASAP means CONSIDER landing at the nearest suitable, it does not mean land at the nearest. The report clearly indicates the crew did consider ASP, and then chose not to go there which is entirely their operational decision to make.

I only grabbed the post because to my Airbus uneducated mind, the points made seem operationally logical, company practical and within the realms of command decision making. Sure bang some heads for the bloody awful engine handling, demand clear SOP and etc. But I think – in those circumstances – I may well have gone to MEL. But I was not there, neither were the ATSB, only the flight crew were.

Not only is the report unpardonably late (again). This is, (once again) not a ‘balanced’ report from the ATSB. As usual they choose to pontificate and take the high ‘safety ground’ – across the board, slanting reports to favour the dictates of their masters, rather than presenting a balanced, calm, even handed, factual, operationally sound report which may assist future aircrew thinking in an abnormal – i.e. not an ‘emergency’ situation…

Toot - toot

[Peetwo]

Hooded Canary: Under the cover of the Xmas bushfire crisis? -   

Excellent p/u "K" -   

Quote:

..Not only is the report unpardonably late (again). This is, (once again) not a ‘balanced’ report from the ATSB. As usual they choose to pontificate and take the high ‘safety ground’ – across the board, slanting reports to favour the dictates of their masters, rather than presenting a balanced, calm, even handed, factual, operationally sound report which may assist future aircrew thinking in an abnormal – i.e. not an ‘emergency’ situation…

Taking up where you left off (above) and while trolling the Hooded Canary's (still) growing list of O&O investigations I made some OBS on the AI-2018-010 investigation which I subsequently transcribed, with pictures to Twitter - 

Via Twitter: https://twitter.com/PAIN_NET1/status/121...3376933888

@atsbgovau
RT Investigation: AI-2018-010 - The approval processes for the Bulla Road Precinct Retail Outlet Centre https://atsb.gov.au/publications/investi...dc.twitter Delayed yet again to 1st quarter 2020, one has to ask what could possibly be the delay? Food for thought?
@pwhatch A duty of care. - Part II ...

---

...Note the date the nearly 3 year @atsbgovau
inquiry was  put back/delayed for completion (ie 16 December 2019) on the cover of
@ScottMorrisonMP OS in Hawaii and the NFI Acting PM @M_McCormackMP
hiding in Wagga while the bush fire crisis escalated, meanwhile the Hooded Canary...

---

......discretely obfuscates yet again this potentially internationally embarrassing report? MT: #EssendonDFOaccident:
@cnegroni
https://auntypru.com/essendon-dfo-accide...christine/ & https://auntypru.com/forum/showthread.ph...76#pid9476 #FederalICACNOW

TBC...P2 

[Peetwo]

RAAus v ATSB: Occurrence reporting disconnections? 

References:

P7’ s Opinion – delivered; as requested.

“Given the size and scope of the RA Oz ‘incident and accident’ list; reading through the responses made to those events; we thought it may germane to take a closer look. ‘K’ is still fuming over the following, to cranky to be impartial. “Can you do it?” Well I’m as appalled as he, however; I’ll take a shot. Lets see”.

Plus:

...Next I have a QoN for Hitch off Oz Flying - http://www.australianflying.com.au/lates...n-approval - in relation this para??

..ASQA's decision is being seen as another blow for Soar after a string of incidents including crashes of Bristells at Stawell and Moorabbin and another incident at Drouin, Victoria, on Christmas Eve when a Bristell struck trees during a practice forced landing...

Where did you get the underlined information from? The reason being that I have checked both the RAAus - Accident & defect summary - and the ATSB aviation occurrence database without any success in tracking down that particular incident??

However as an aside, while trolling through those latest RAAus incidents, I was disturbed by the number of a) reported incidents (30 from 1 December 2019 to today) and the naive admissions of b) very poor airmanship, basic aeronautical knowledge and blatant disregard for the rules...  

This one was most disturbing:     

...Inadvertent flight into IMC: The aircraft departed Narromine into significant smoke haze. At 500' the pilot could see objects out to about 10NM but could not see the horizon. At cruise altitude of 4,500' visibility became worse. The visual cues indicating the aircraft's attitude became degraded. The pilot could judge pitch and roll only by looking at the paddocks and roads within a 45 degree cone beneath the aircraft. When they were head-down looking up the latest weather details for their next stop at Griffith the pilot glanced sideways at the ground to see if they were still wings-level and all seemed OK until they saw the artificial horizon on the EFIS which indicated that they were in a 15 degree bank. The pilot knew then what IMC was they then engaged the autopilot so the next time they were head-down in the cockpit they weren’t going to give themselves another fright. The smoke progressively thinned out towards Griffith and visibility entering the circuit was satisfactory until initiating their turn to base. The pilot seemed to have descended into a lens of smoke which totally blocked their view of the runway, but views crosswind and downwind were relatively clear. The pilot estimated where the extended centreline of the runway was and turned final only to find, when exiting the smoke lens, that they had turned too soon, requiring a dog-leg correction to get back on the centreline...

 
Now I know that the basic RAAus aircraft are only allowed to carry two POB outside of radar CTA but in hindsight if you were the miniscule responsible for oversighting aviation safety would you be prepared to actively promote an aviation business flogging around in aircraft not properly certified for the purposes of training young pilots to fly, while overflying large built up urban areas adjacent to secondary airports that you are also ultimately responsible for...  

Other than the possible nomination for this year's Darwin awards (see posts above) I decided on taking a bit of a closer look see at the RAAus 'Accident and defect summary' webpage which I can only assume is an integral part of the association's SMS which (depending on the seriousness of the accident/incident) by design should be tied to the ATSB National Aviation Occurrence database and ultimately approved by CASA?

With a short bit of digging on the RAAus website I was able to establish that RAAus do facilitate, indeed take responsibility for, the forwarding of mandatory occurrence reports to the ATSB - see HERE:

Recreational Aviation Australia is required to meet statutory reporting requirements under the Transport Safety Investigation Act 2003.

Reportable matters are categorised as:

IRM: Immediately reportable matters

RRM: Routinely reportable matters

By submitting a report we are able to submit your information directly to the Australian Transport Safety Bureau.

Click below to acknowledge your approval for Recreational Aviation Australia to submit the report to the Australian Transport Safety Bureau on behalf of you.

From the ATSB website, this is the loosely defined definitions for IRMs & RRPs:

What is an immediately reportable matter?

ANSWER:
An immediately reportable matter is a serious transport safety matter that covers occurrences such as accidents involving death, serious injury, destruction of, or serious damage to vehicles or property or when an accident nearly occurred. Under section 18 of the TSI Act, immediately reportable matters must be reported to a nominated official by a responsible person as soon as is reasonably practical. The reason for such a requirement is the need for ATSB investigators to act as quickly as possible is often paramount in order to preserve valuable evidence and thus to determine the proximal and underlying factors that led to a serious occurrence.
The list of immediately reportable matters for each mode of transport is contained in the TSI Regulations. Immediately reportable matters are the only transport safety matters that need to be reported for the marine mode of transport. In aviation and rail where the Commonwealth, and hence the ATSB, has more comprehensive responsibilities for the investigation of transport safety matters there is also a list of routine reportable matters.

What is a routine reportable matter?

ANSWER:
A routine reportable matter is a transport safety matter that has not had a serious outcome and does not require an immediate report but transport safety was affected or could have been affected. Under section 19 of the TSI Act a responsible person who has knowledge of a routine reportable matter must report it within 72 hours with a written report to a nominated official.
The list of routine reportable matters are contained in the TSI Regulations. Routine reportable matters only exist for aviation and rail and would include a non-serious injury or the aviation or rail vehicle suffering minor damage or structural failure that does not significantly affect the structural integrity, performance characteristics of the vehicle and does not require major repair or replacement of the affected components.

Routine reportable matters exist only for aviation and rail as the Commonwealth has wide ranging responsibilities for aviation matters because of the nature of the industry in which all aircraft are subject to the same control. In the marine transport mode the ATSB concentrates on serious safety matters in relation to international and/or interstate transport only as the Commonwealth does not have sole responsibility for these modes.

---

And from the TSI Act:

 All aircraft operations

         (1)   For the purposes of the definition of immediately reportable matter in subsection 3 (1) of the Act, the following investigable matters, in relation to an aircraft operation (other than an aircraft operation mentioned in subregulation 2.1 (2)), are prescribed:

                (a)    subject to subregulation (2), the death of, or a serious injury to:

                          (i)    a person on board the aircraft or in contact with the aircraft or anything attached to the aircraft or anything that has become detached from the aircraft; or

                         (ii)    a person who has been directly exposed to jet blast;

               (b)    the aircraft being missing;

                ©    the aircraft suffering serious damage, or the existence of reasonable grounds for believing that the aircraft has suffered serious damage;

               (d)    the aircraft being inaccessible and the existence of reasonable grounds for believing that the aircraft has been seriously damaged;

                (e)    breakdown of separation standards, being a failure to maintain a recognised separation standard (vertical, lateral or longitudinal) between aircraft that are being provided with an air traffic service separation service.


Aircraft operations other than air transport operations

         (2)   For the purposes of the definition of routine reportable matter in subsection 3 (1) of the Act, the following investigable matters, in relation to an aircraft operation (other than an aircraft operation mentioned in subregulation 2.1 (2) or an air transport operation), are prescribed:

                (a)    an injury, other than a serious injury, to a person on board the aircraft;

               (b)    a flight crew member becoming incapacitated while operating the aircraft;

                ©    airprox;

               (d)    an occurrence in which flight into terrain is narrowly avoided;

                (e)    the use of any procedure for overcoming an emergency;

                (f)    an occurrence that results in difficulty controlling the aircraft, including any of the following occurrences:

                          (i)    an aircraft system failure;

                         (ii)    a weather phenomenon;

                        (iii)    operation outside the aircraft’s approved flight envelope;

               (g)    fuel exhaustion;

               (h)    the aircraft’s supply of useable fuel becoming so low (whether or not as a result of fuel starvation) that the safety of the aircraft is compromised;

                (i)    a collision with an animal, including a bird, on a licensed aerodrome.

Now although some of the 30 odd A&D summaries from the 1sr December 2019 to now certainly don't meet the requirements for mandatory reporting, there are IMO significant number that do and therefore should be reflected/recorded on the ATSB aviation occurrence database.

This of course took me to the ATSB database search page, where I put in the same time frame for reported accident/incidents and came up with the following Excel spreadsheet link: https://auntypru.com/wp-content/uploads/...lts-1.xlsx

A basic summary of that file reads as there being a total of 43 reported occurrences, 18 of which were accidents, 15 being incidents of which 10 were classified as serious and of those 43 occurrences the ATSB will be investigating 7.

All good so far? Now let's go back to the 31 entries (spread over 3 pages) for the same time frame (ie 1 December to today) of the RAAus A&D summaries and apply the ATSB mandatory reporting filters for IRMs & RRMs.

To test the integrity for what would definitely be classified as an IRM, on the 16 December there was a fatal accident involving a Bristill (BRM Aero) aircraft:

Fatal Accident involving RAAus member. RAAus accident consultants are assisting police in determining the causal factors that led to the accident.

     
Which we see corresponds to the ATSB spreadsheet: 

Okay integrity tested, next we will go to the 1st entry for the time frame off the A&D pages, which I would of thought still met the requirements for an IRM?

The aircraft lost power at 4000ft with the engine reduced to idle (900 RPM). The option was taken to return to the airport. Carb heat was applied for icing and a forced landing procedure was enacted. A best L/D is achieved at 70kts. RWY 23 became unachievable with a stronger wind of 15-20kts. The engine remained at idle till switches were cut at 200ft AGL. The undercarriage struck a fence with the aircraft at stall point resulting in the aircraft impacting the ground nose first however it did not become inverted.

However off the ATSB webpage there would appear to be no record for the 72 hours post accident:



Hmm...so maybe it was lost in the mail?

Next entry for the 1st of December reads:

Whilst conducting circuits at YSBK RWY 29L. The Bristell was following a Sling which was marginally slower and performing circuits wider than theirs. Upon unsuccessfully attempting to create sufficient spacing Tower directed the Bristell to perform a go around. The go around was performed and attempts were made to climb and divert to the left side of RWY 29L however the pilot did not divert enough to create sufficient spacing.

Although possibly not an IRM, it definitely meets the requirements for a RRM and as can be seen at this point in time it is not recorded on the ATSB database. Again maybe lost in the mail??

Next we go to the 3rd of December A&D entry:

On landing in the flare there was a wind gust. The aeroplane sank quite fast and bounced. The pilot applied full power to go around. The second landing was successful with a smooth touch down but the pilot struggled with directional control. The pilot got the aircraft back under control but on return to the hangar it was found that the propeller tips had struck the ground.

  
By definition at least an RRM but again no entry?

Next to the 1st page and entry for what was presumably a Soar Aviation aircraft:

At PIPS, the student noted the master caution light come on and start flashing. Passing Carrum, the student descended to 1000 approaching Mordialloc pier and started noticing a blank noise. Student conducted radio failure check to confirm whether they actually had a failure or not. Student took it as a radio failure. Transmitting blind, they squawked 7600 then made call joining downwind RWY17R, did not hear any response. Joining base, the student heard static and then the tower respond and the radio came back live again. The student was advised to change transponder back to 3000 which they did and they were given landing clearance and landed safely.

 
Again possibly not an IRM but because it involved ATC and a recognised emergency procedure, I would have thought at least a RRM should have been submitted but again no report recorded.

Next I'll skip to the New Year and an entry for the 10th of January with yet another Jabiru engine failure:

The aircraft experienced a severe engine vibration followed by complete engine failure whilst on downwind RWY 03. The pilot conducted a successful forced landing on RWY 03.

  
Again the same result - NO ENTRY???

I could go on...and on...but I think that most people with at least half a brain get the message...  

MTF...P2 

Ps Oh and by the way - it should not come as any surprise that the BRB nomination for this year's Darwin awards has also not been submitted to the ATSB??

So we bury him; then we look to the accident investigation for guidance and find twaddle like this:-


..."Inadvertent flight into IMC: The aircraft departed Narromine into significant smoke haze. At 500' the pilot could see objects out to about 10NM but could not see the horizon. At cruise altitude of 4,500' visibility became worse. The visual cues indicating the aircraft's attitude became degraded. The pilot could judge pitch and roll only by looking at the paddocks and roads within a 45 degree cone beneath the aircraft. When they were head-down looking up the latest weather details for their next stop at Griffith the pilot glanced sideways at the ground to see if they were still wings-level and all seemed OK until they saw the artificial horizon on the EFIS which indicated that they were in a 15 degree bank. The pilot knew then what IMC was they then engaged the autopilot so the next time they were head-down in the cockpit they weren’t going to give themselves another fright. The smoke progressively thinned out towards Griffith and visibility entering the circuit was satisfactory until initiating their turn to base. The pilot seemed to have descended into a lens of smoke which totally blocked their view of the runway, but views crosswind and downwind were relatively clear. The pilot estimated where the extended centreline of the runway was and turned final only to find, when exiting the smoke lens, that they had turned too soon, requiring a dog-leg correction to get back on the centreline...

That is an example of ‘internal’ investigation?

What the minister has sanctioned, what CASA have encouraged to develop and what has been taken advantage of demands immediate inquiry. IMO the AFP need to become involved and the inquiry needs to be oversighted and completed by an independent chair. This situation is wrong on so many levels, particularly when the likes of Angel Flight and Buckley are being beaten into the ground. I say enough is enough; time to stop the merry go-round. Start by disillusioning the minister.

 
Hmm...what was that St Commode said in relation to a VFR into IMC accident - 

Ref: https://auntypru.com/sbg-3-03-2019-or-ra...less-vain/